Citation
Assessing willingness to integrate the mentally ill into community life

Material Information

Title:
Assessing willingness to integrate the mentally ill into community life
Creator:
Hagood, E. Allison
Place of Publication:
Denver, Colo.
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
Physical Description:
74 leaves : ; 28 cm

Thesis/Dissertation Information

Degree:
Master of Arts
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Psychology, DU Denver
Degree Disciplines:
Clinical Psychology
Committee Chair:
Berrenberg, Joy L.
Committee Members:
Coussons-Read, Mary E.
Handelsman, Mitchell M.

Subjects

Subjects / Keywords:
Mentally ill -- Public opinion ( lcsh )
Mentally ill -- Deinstitutionalization -- Public opinion ( lcsh )
Community mental health services -- Utilization ( lcsh )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Bibliography:
Includes bibliographical references (leaves 67-74).
General Note:
Department of Psychology
Statement of Responsibility:
by E. Allison Hagood.

Record Information

Source Institution:
|University of Colorado Denver
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
47826446 ( OCLC )
ocm47826446
Classification:
LD1190.L645 2001m .H33 ( lcc )

Full Text
ASSESSING WILLINGNESS TO INTEGRATE THE MENTALLY ILL
INTO COMMUNITY LIFE
by
E. Allison Hagood
B.A., Harvard University, 1988
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Master of Arts
Clinical Psychology


This thesis for the Master of Arts
degree by
E. Allison Hagood
has been approved
by


Hagood, E. Allison (M.A., Clinical Psychology)
Assessing Willingness to Integrate the Mentally 111 into Community Life
Thesis directed by Associate Professor Joy L. Berrenberg
ABSTRACT
The author developed a measure to assess willingness to integrate people with
mental illnesses into community life. One hundred and seventy-three
undergraduates answered 47 items designed to evaluate this construct. Internal and
temporal reliability was robust, as was convergent and discriminant validity. The
results indicated some potential problems with group validity; groups that were
expected to score differently on the scale did not do so. Future work with the scale
should identify ways to increase group validity and establish predictive validity.
The scale may be useful for identifying neighborhoods that would accept
community-based treatment options and placing these facilities in such areas. The
scale may also help determine which types of educational programs would increase
willingness to integrate the mentally ill into community life.
This abstract accurately represents the content of the candidates thesis. I
recommend its publication.
Signe
iii


DEDICATION
I dedicate this thesis to my family and friends for their unwavering support of me
throughout the completion of this project, and to people with mental illness, some
whom have allowed me the honor of being a part of their lives.


ACKNOWLEDGEMENT
I would like to thank my advisor, Joy L. Berrenberg, for her patience with me and
support of this project. I also wish to thank the faculty of the Department of
Psychology for their encouragement, patience and support.


CONTENTS
Tables.........................................................viii
CHAPTER
1. INTRODUCTION......................................................1
History of Deinstitutionalization.................................1
Community-Based Treatment.........................................4
Attitudes Toward the Mentally 111.................................9
Identify Supportive Communities..................................11
2. METHOD...........................................................18
Participants.....................................................18
Scale Development................................................18
Questionnaires and Procedures....................................20
3. RESULTS..........................................................25
Item Analysis....................................................25
Factor Analysis..................................................31
Normative Data...................................................32
Reliability......................................................35
Validity.........................................................35
Construct Validity.........................................35
vi


Group Validity...........................................37
4. DISCUSSION.....................................................39
5. SUMMARY........................................................48
APPENDIX
A. The Attitudes toward Mainstreaming the Mentally 111 Scale.49
B. The Community Attitudes to the Mentally 111 Scale.........54
C. The Social Rejection Scale.................................58
D. The Hogan Empathy Scale....................................60
E. Permission Letter from the University of Minnesota Press...61
F. Permission Letter from Consulting Psychologists Press, Inc.62
G. The Marlowe-Crowne Social Desirability Scale................64
REFERENCES........................................................67
vii


TABLES
Table
3.1 Item/total correlations for the AMMI Scale.................................27
3.2 Item/criterion correlations between each AMMI Scale item and the
validity scales (CAM3, Social Rejection Scale, Social Desirability Scale,
Empathy Scale.............................................................28
3.3 Normative data for college sample, separated by..........................32
3.4 Normative data for college sample as a whole, and separated by gender. .33
3.5 Normative data for the validation scales for sample as a whole and
separated by gender.......................................................34
3.6 Convergent and discrimination validity data................................36
3.7 Normative data separated by familiarity group..............................37
viii


CHAPTER 1
INTRODUCTION
The move from institutional to outpatient care for those with mental
illnesses, plus the attendant need for more community-based facilities, has created
several new challenges for the mental health profession. Societal resistance to the
mainstreaming of individuals with severe mental illnesses is one of those
challenges. This thesis will describe some of the issues related to this challenge and
discuss the development of a scale to assess community attitudes regarding
integrating the mentally ill into community settings such as neighborhoods, places
of employment, and schools.
History of Deinstitutionalization
A combination of historical, sociological, and therapeutic changes created a
push toward moving people out of facilities in which the mentally ill were
warehoused, with little chance for improvement or rehabilitation, and into
community-based settings. In the early part of this century, persons with mental
illnesses, especially severe ones, were treated by virtual imprisonment in large
hospital facilities. They rarely received adequate therapy and almost never returned
to society in a fully functioning capacity, if they managed to leave the institution at
1


all. The mental hygiene movement started by Clifford Beers in 1909 attempted to
change this trend by advocating early treatment of mental disorders and by
presenting the first early ideas of community-based care (Winslow, 1933;
Thompson, 1994).
Gradually, society became less tolerant of the idea of institutional care. By
it.
1961, the Joint Commission on Mental Illness and Health had gone so far as to
recommend that no new mental hospitals be built and that existing state hospitals
should be gradually and progressively converted into centers for the long-term and
combined care of chronic diseases, including mental illness (Joint Commission on
Mental Illness and Health, 1961, p. xvi). This recommendation resulted in a
national proposal which, among other things, called for the development of
community mental health centers. These centers were to provide services including
inpatient, emergency, partial (or day), and outpatient treatment, as well as
educational programs to insure a better community understand of mental illness.
The changing attitudes toward the mentally ill were occurring
simultaneously with improving methods of treatment. The development of
psychotropic drugs, begun in Europe in the first half of the century, resulted in some
astounding cures for long-institutionalized patients. In 1949, lithium carbonate
was found to be useful in calming agitation in persons with serious mental illnesses,
and in 1950, Thorazine, the first medication found to alleviate psychotic symptoms
themselves, was placed into use in the early 1950s. (Kaplan, Sadock & Grebb,
2


1994). Afterwards, the use of pharmacotherapy became a standard intervention,
particularly for persons with severe mental illnesses, who coincidentally were most
often the ones found in the warehouse institutions. The availability of effective
psychotropic drugs combined with the changing societal attitudes to create the
deinstitutionalization movement (Grob, 1983).
Deinstitutionalization has been defined as a process involving two
elements: (1) the eschewai of traditional institutional settings primarily state
hospitals for the care of the [chronically] mentally ill, and (2) the concurrent
expansion of community-based services for the treatment of these individuals
(Bachrach, 1976, p. 1). The first element is reflected in an enormous decline of
hospital bed usage and availability. The resident census of state mental hospital
facilities in 1955 was approximately 559,000; by 1980, this had dropped to
approximately 138,000 (Goldman, 1983). In Colorado alone, the Colorado Mental
Health Institute in Pueblo dropped from a peak patient census of approximately
6,075 in 1960 to approximately 10% of that by the mid-1980s (Hawkins, 1998).
This declining trend in hospital-based care is not limited to the United States. For
example, in Australia in 1957 there were 340 inpatient psychiatric hospital beds per
100,000 citizens. By 1994 that number had dropped to 46 beds per 100,000
citizens (Wilton, 1994).
The reasons for the decline in inpatient psychiatric beds were both economic
and therapeutic. Community-based care is much more cost-effective than care
3


within traditional institution settings (Bachrach, 1983). The increasing cost of
mental health services served as an impetus for moving people into community-
based settings (Bachrach, 1976, 1978; Gruenberg & Archer, 1979). However, it is
not possible to implement adequately either the philosophical (treatment-oriented)
and economic (cost-reduction-oriented) policies regarding deinstitutionalization
without appropriate community-based programs to replace the institutional system
(Eamon, 1994). Attempts to implement the replacement programs have been
stymied by a number of obstacles, such as community opposition.
Community-Based Treatment
There are many different components of community-based treatment. These
include treatment facilities such as community mental health centers, residential
settings that teach individuals basic life skills, vocational rehabilitation programs
that train people in new job skills, housing that includes supervision by trained
professionals, and support or drop-in centers to assist people in coping with the
symptoms of their illness. For the purposes of this thesis, community-based
treatment will include any treatment modality outside of an inpatient hospital
setting.
Therapeutically, community-based treatment has much to recommend it over
inpatient treatment settings. Simple upgrades in hospital treatment, while leading to
accelerated improvement within the hospital setting and earlier discharge from that
4


setting, have not improved posthospital adjustment for patients (Anthony, Buell,
Sharratt, & AlthofF, 1972). In contrast, numerous studies have shown that a
combination of supported housing, medication monitoring, life-skills training,
psycho-educational training and community-based treatment are most effective for
this population, increasing quality of life and level of self-care (Carpenter, 1978;
Dellario, 1982; Forchuck, 1991; Gutheil, 1985; Kahn & Frederick, 1988; Lehman,
1983).
Along with having positive effects on quality of life and self-care,
community-based treatment is beneficial in many other ways. Hospitalization rates
for clients in community-based residential treatment decrease after clients receive
behavior training in basic self-care tasks (Corrigan, Davies-Farmer, Lightstone, &
Stolley, 1990). Increasing the structure and expectations of behavior within a
community care facility tends to stretch ego boundaries and encourage growth
(Gottesman, Peskin, Kennedy & Mossey, 1991, p. 245). Residents of community
based residential facilities rated highly structured residential programs (with rigid
treatment and participation expectations, for example) as being extremely helpful
(Goering, Sylph, Foster & Boyles, 1992). Individuals who cease to receive
structured treatment while living in a community-based care facility showed
significant decreases in Global Assessment Scale scores, and these decreases were
highly correlated to cessation of treatment (Baker, Jodrey, Intagliata & Straus,
1993).
5


Certain symptoms unique to chronic mental disorders also respond favorably
to community-based residential treatment. For example, persons with schizophrenia
often exhibit a characteristic hostility due to paranoia. This hostility abates
somewhat with treatment, but a significant number of persons with this diagnosis
continue to manifest some residual hostility and mistrust. This characteristic is a
leading cause of the serious societal stigmatization of this population, and is
strongly associated with psychosocial difficulties as well as with non-compliance
with medications regimes and with ongoing substance abuse (Bartels, 1991).
Supported therapeutic housing facilities can ease these psychosocial difficulties by
ensuring stability of housing, finances and other necessities, and providing
medication and substance abuse monitoring (Carling, 1992), as well as or better than
inpatient treatment.
When the research literature is taken as a whole, community-based treatment
is always as effective or more effective than inpatient treatment in assisting people
with mental illnesses in achieving employment and community living, and reducing
the use of medication and outpatient services (Carling, 1992). The presence of such
programs can almost completely remove the need for hospitalization, but that this
beneficial effect is possible only as long as the special community treatment
program is in place. Hospitalization rates increase once supportive community
treatment ends. This increase emphasizes the need for ongoing programs rather
than time-limited ones (Test & Stein, 1978).
6


The efficacy of community-based treatment programs depends in part on the
reaction of the surrounding community to the treatment facility. Treatment
outcomes such as alleviation of some psychiatric symptoms (such as hostility) and
enhancement of quality of life occur more quickly when the community accepts the
treatment facility and integrates it into community life (Baker, Jodrey, Intagliata &
Strauss, 1993; Biegel, Tracy & Corvo, 1994; Brinck, 1994; Newman, Reschovsky,
Kaneda & Hendrick, 1994; Svab-Cotic, 1994). Persons who are supported by their
communities are healthier than those who lack such support (Buchanan, 1995).
Contact with psychiatric treatment services is negatively correlated with social
networks, with the effects being most severe for long-term psychiatric patients
(Greene, 1983).
Studies show that community characteristics are in some ways more
important that the characteristics of people with mental illnesses in terms of
predicting how much the mentally ill will actually participate in community life
(Carling, 1992). For instance, distance to resources and services is a crucial
component of social integration, and middle-class suburban neighborhoods maybe
have a negative impact on integration due to the distance from resources such as
grocery stores, recreation centers, and health care options (Segal & Aviram, 1978).
However, more positive attitudes toward integration have been found in
communities with higher educational backgrounds, higher socio-economic status
and younger ages (Wahass & Kent, 1997), and these attitudes may counteract the
7


negative effects of distance from services. As these studies show, communities
possess the ability to provide a full range of needed services for patients with
severe mental disabilities; and... communities may sometimes be encouraged to
assume initiative and responsibility in the care of their most severely impaired
members. (Bachrach, 1983, p. 9).
When mental health treatment programs move into a community, they
encounter a variety of community reactions. Some communities tolerate treatment
facilities in their midst, while some show passive resistance or active opposition
(Morrison, deMan & Drumheller, 1993; Rossler, Salize & Voges, 1994; Wolff,
Pathare, Craig & Leff, 1996a, 1996b). In the authors capacity as a supervisor of a
community-based residential treatment continuum, she attempted to relocate one
supported independent living facility from one neighborhood to another. During
this process, petitions were circulated in the target neighborhood calling for
residents to oppose the move. Community meetings were held to answer residents
concerns, and the number of people participating in these meetings was much
greater than the number of signatures on the petition, indicating that unspoken
opposition existed as well as the active objections noted in the petition. Other
personnel attempting to establish residential facilities have encountered similar
difficulties.
Such opposition both stems from the stigma associated with mental illness,
and in a vicious cycle, continues to perpetuate the same stigma by failing to change
8


community attitudes. Stigma, the negative attitudes regarding mental illness, has
been shown to slow the recovery rate and lower improvement levels of patients
(Harding, Zubin & Strauss, 1987). Unfortunately, community-based services for
persons with severe mental illnesses still are conducted in an environment of stigma
that is exceedingly difficult to overcome. Community treatment is often rejected by
the community (Anthony, Cohen & Cohen, 1983), as often as it is accepted. This is
unfortunate, as:
The very nature of a community support system calls for the active
involvement of a wide range of interest groups: consumers, parents,
citizens, landlords, neighbors, hospital and community mental health
workers, other human services workers, and administrators and policy
makers at all levels. (National Institute of Mental Health, p. 3-4).
Clearly, the consensus is that the success of community-based treatment is
fundamentally related to the acceptance of persons with mental illnesses into the
community (e.g., Carling, 1992, Cousens & Crawford, 1988, National Association
of State Mental Health Program Directors, 1987).
Attitudes Toward the Mentally 111
A wide variety of studies have shown that most people, both in America and
abroad, continue to hold negative attitudes about mental illness (e.g., Aubry, Tefft,
& Currie, 1995; Barry, 1994; Bhugra, 1989; Brockington, Hall, Levings & Murphy,
1993). These attitudes are not restricted to the lay population; research has also
indicated the presence of negative stereotypes about mental illness within the mental
9


health disciplines themselves, attitudes that have proven remarkably impervious to
change over time (De-Nour & Weisstub, 1981; Fabrega, 1995; Gillig, Hillard,
Deddens, Bell & Combs, 1990; Keane, 1991; Packer, Prendergast, Wasylenki,
Toner & Ali, 1994; Weller & Grunes, 1988). Negative attitudes have a significant
impact on the deficits in functioning and quality of life associated with mental
illness. People are less likely to hire persons with the label of mental illness
(Bordieri & Drehmer, 1986; Farina & Felner, 1973). They are also less likely to
allow them to rent or lease apartments (Page, 1977, 1983, 1995), and such housing
discrimination based on stigma denies individuals access to normal housing
(Carling, 1992). Ongoing research in the field of attitudes toward people with
mental illness indicate that the mentally ill are regarded with distrust, dislike, and
fear, and are considered dangerous, dirty, unpredictable and worthless (Corrigan &
Penn, 1999;Bhugra, 1989; Wahl, 1995).
Needless to say, such attitudes lead to the stigmatization and ostracizing of
people with mental illnesses. As a result, people with mental illnesses, especially
severe ones, may reside in a community without becoming an active part of that
community. This isolation is counter-therapeutic, as the importance of social
support systems in the treatment of chronic mental patients has been well-
documented (Stein, 1979; Biegel, Tracy & Corvo, 1994). Lack of adequate support
systems increases isolation in the community and leads in many cases to
exacerbation of symptomology. Unfortunately, persons with severe mental illnesses
10


often manifest difficulties in behavior and interpersonal skills that make
spontaneous interpersonal experiences difficult for them (Cotton, 1983). Therefore,
rehabilitation outcomes appear to depend on both the clients skills and on the
support he or she received from the community (Anthony, Cohen & Cohen, 1983).
Based on the above evidence, in order to ensure effective community-based
treatment, mental health service providers should strive to ascertain the existence of
positive community attitudes, because doing so will produce better outcomes for
patients. Also, better treatment outcomes translate into lower overall costs for
treatment. Therefore, managed mental health care providers would also benefit by
identifying supportive neighborhoods in which to place facilities.
Identify Supportive Communities
The research on attitudes regarding community-based mental health services
suffers from the lack of a psychometrically sound (and therefore valid) tool for
assessing community attitudes toward reintegrating the mentally ill. Most of the
studies in this area have used scales with questionable psychometric properties (e.g.,
Bums, Goddard & Bale, 1995; Epstein, Sage & Wedding, 1995). In some instances,
researchers have provided subjects with vignettes portraying persons with various
mental disorders and then used unvalidated questionnaires to assess attitudes toward
these people (Angermeyer & Matschinger, 1995; Aubry, Tefft, & Currie, 1995;
Barry, 1994; Rossler & Salize, 1995; Rossler, Salize & Voges, 1995).
11


Several validated scales have been developed to assess attitudes toward
mental illness and persons with mental illness. However, some of these were
designed for use with very specific populations. For example, the Patient Rejection
Scale (Bailer, Rist, Brauer & Rey, 1994) was developed to assess attitudes of
relatives of mental patients. The Residents Attitudes Toward the Chronically
Mentally 111 Scale (Packer, Predergast, Wasylenki, Toner & Ali, 1994) is
appropriate only for psychiatric residents. A Social Rejection Scale (Trute &
Loewen, 1978) assesses attitudes toward persons who have been hospitalized for
psychiatric diagnoses in the past, but who are considered recovered or cured.
None of these scales are appropriate for use in assessing attitudes toward integrating
the mentally ill in a general community population.
There are two scales that do in fact assess general community attitudes: the
Opinions of Mental Illness (OMI) Scale (Cohen & Struening, 1962) and the
Community Attitudes to the Mentally HI (CAMI) Scale (Taylor & Dear, 1981). The
OMI Scale was developed in 1962, and normed on a population of medical school
student residents. This 51-item scale contains five subscales: Authoritarianism,
Benevolence, Mental Hygiene Ideology, Social Restrictiveness, and Interpersonal
Etiology. The OMI is one of the most widely used scales for assessing attitudes
toward those with mental illness (e.g., Rabkin, 1975).
However, there are a number of problems with the Opinions of Mental
Illness Scale. First, because the scale was developed in 1962 before the original
12


movement toward deinstitutionalization and before the Community Mental Health
Centers Act was signed, it is somewhat out of date. The extensive public education
and information regarding mental illness that has been disseminated since that time
makes it unlikely that the original items are valid. For example, many well-known
persons, such as Mike Wallace of 60 Minutes and the actress Patty Duke, have made
public admissions of having suffered from mental illnesses. The amount of
publicity received by these stories make it unlikely that items such as To become a
patient in a mental hospital is to become a failure in life, or Regardless of how
you look at it, patients with severe mental illness are no longer really human,
would generate much response variability in todays survey populations.
Second, most, if not all, of the psychotropic medications currently used to
treat mental illness have been discovered since the OMI Scale was first introduced.
These medications have enabled many persons suffering from severe mental illness
to resume normal functioning. The success of these medications has stopped the
relegation of mental illness to the back wards of warehouse hospitals, and so such
items on the OMI Scale as Every mental hospital should be surrounded by a high
fence and guards or There is little that can be done for patients in a mental
hospital except to see that they are comfortable and well fed, would be
inappropriate.
In 1981, Taylor & Dear updated the OMI Scale to the Community Attitudes
to the Mentally 111 Scale. This research team combined several items from the
13


Authoritarianism subscale (3), the Benevolent subscale (2), and the Social
Restrictiveness subscale (2) that were left intact from the original OMI Scale, as
well as four items associated with authoritarian attitudes from the Custodial Mental
Illness Ideology Scale (Gilbert & Levinson, 1956). In addition, the authors added a
fourth subscale called the Community Mental Health Ideology subscale, based
conceptually upon the original Community Mental Health Ideology Scale (Baker &
Schulberg, 1967) but with significant alterations to the items. The remaining items
were updates of the original items found in the OMI Scale, but, according to the
authors do not alter significantly the content domains of the scales as originally
conceived (Taylor & Dear, 1981, p. 228.) The resulting CAMI Scale was pilot-
tested on a large sample of the community population of Toronto, and has
reasonably sound psychometric properties, with item/total correlations for the four
subscales ranging from .34 to .61, and alpha coefficients for the four subscales
ranging from .68 to .88.
There are several weaknesses in the CAMI Scale. First, the original factor
structure proposed by Taylor & Dear (1981) is not robust, as several subsequent
studies have identified differing factor structures (Brockington, Hall, Levings, &
Murphy, 1993; Wolff, Pathare, Craig & Leff, 1996a). Second, the CAMI Scale has
been used in relatively few studies, and thus its psychometric properties have not
been fully explored. Finally, the items on the CAMI scale measure global
attitudes toward mental illness; that is, attitudes toward the concept of mental illness
14


in general. These items do not measure personal attitudes toward mental illness;
that is, attitudes toward incorporating a person with mental illness into daily
community life.
While both the OMI Scale and the CAMI Scale purport to measure
community attitudes toward persons with mental illness, they do not assess attitudes
toward integration of community-based treatment programs. Community members
may report one set of attitudes toward the mentally ill in general, and quite another
when asked to consider the integration of these persons into their own community.
Since service providers and healthcare organizations most benefit by locating
congenial neighborhoods in which to place treatment facilities, a scale specifically
designed to assess the willingness of community members to accept the placement
of persons with mental illness into their neighborhoods, schools, and employment
settings would be highly desirable. Such a scale already exists for assessing
community receptivity toward persons with mental retardation. The Community
Living Attitudes Scale, Mental Retardation Form (CLAS-MR) (Henry, Keys, Jopp,
& Balcazar, 1996) consists of four subscales that measure attitudes about
reintegration and rehabilitation for the mentally retarded. The benefit of this scale is
that it can more accurately quantify acceptance of the mentally retarded into
community life on the personal as opposed to general level.
The purpose of this thesis, therefore, is to extend and refine a scale
developed to assess community attitudes toward reintegrating the mentally ill into
15


community settings. The Attitudes Toward Mainstreaming the Chronically
Mentally 111 (ATMCMI) Scale was developed and piloted in 1995 by the author of
this thesis, with 20 items designed to assess attitudes toward the reintegration of
persons with chronic mental illness into school, work and residential community
settings. Internal consistency reliability, measured using Cronbachs Coefficient
Alpha, was strong (a = .92), as was convergent validity with the Social
Restrictiveness Subscale of the OMI (r = -.64, p < .05) and the Mental Hygiene
Ideology subscale of the OMI (r = 62, p < .05).
In spite of the promising results of the ATMCMI pilot study, some
weaknesses exist in the scale as it stands. First, the pilot study did not examine test-
retest reliability in order to establish temporal validity of the construct in question.
Second, the assessment of the scales validity was quite limited. Third, discriminant
validity assessed using the Marlowe-Crowne Social Desirability Scale (Crowne &
Marlowe, 1964) revealed some social desirability response set contamination in the
scale. Also, the pilot sample was small, and gender differences and possible
problems with social desirability contamination could not be explored fully.
Finally, some refinement and expansion of the original ATMCMI item set was
deemed desirable due to the above-mentioned social desirability contamination and
due to the fact that the original item set did not incorporate as wide range of
community settings. The research reported in this thesis addresses these weaknesses
and expands the work begun during the ATMCMI pilot study.
16


New items were developed to expand the original ATMCMT item set. These
items were assessed for face and content validity, and then administered to a group
of undergraduates in two different college settings. Additional scales were
administered as well, in order to establish convergent and discriminant construct
validity. Factor analysis attempted to identify any underlying dimensions of the
scale. Finally, the scale was administered to a group of mental health professionals
in order to establish group validity.
17


CHAPTER 2
METHOD
Participants
The scale was administered to a sample of 173 students in introductory
psychology classes at the University of Colorado at Denver (UCD) (N = 128) and at
Front Range Community College (FRCC) (N = 45) There were 56 males and 115
females in this undergraduate sample. The mean age for the UCD sample was 21.68
years with a standard deviation of 4.84. The UCD sample included 42 males, 84
females, and two subjects that did not indicate gender. The mean age of the FRCC
sample was 25.40 years with a standard deviation of 9.32. The FRCC sample
included with 14 males and 31 females. The scale was also given to a sample of 30
employees of Aurora Mtental Health Center, with a variety of disciplines
represented. There were 13 males and 17 females in this sample, mean age of 31.2
years, with a standard deviation 8.47.
Scale Development
The original 20 items on the ATMCMI were expanded by integrating these
items with new items designed to measure opinions regarding integration of the
18


mentally ill. The items of the resulting draft of the Attitudes toward Mainstreaming
the Mentally HI (AMMI) Scale reflect three setting dimensions
(residential/community, employment, and education) and two distance dimensions
(casual social contact and intimate social contact). All items were reviewed for face
validity and clarity of expression on a group of laypersons and a group of
professionals within the field of mental health. Items deemed redundant, ambiguous
or likely to elicit reactivity such as hostility were eliminated or modified. The
AMMI contains 47 items, each rated on a 7-point Likert scale (Strongly Agree,
Agree, Slightly Agree, Neutral, Slightly Disagree, Disagree, Strongly Disagree).
Higher scores reflect greater willingness to integrate persons with mental illnesses
into the community. In order to control for the possibility of response bias, 18 of
the items were worded to reflect a positive attitude, and 29 to reflect a negative
attitude. In completing the AMMI Scale, respondents are provided with the
following instructions:
For the purposes of this scale only, the term mental illness or
person/people with mental illnesses refers to a person who has an
ongoing mental illness and requires some level of special care, such
as living in a staffed facility or having a special job supervisor. The
person may or may not have required hospitalization in the past, but
does require medication and/or ongoing treatment to remain out of
the hospital.
19


Questionnaires and Procedures
The AMMI Scale (Appendix A) was presented to the college study sample,
along with several other scales to assess its convergent and discriminant validity.
Convergent validity was measured using the CAMI scale (Taylor & Dear, 1981), the
Trute Social Rejection Scale (Trute & Loewen, 1978), and Hogans Empathy Scale
(Hogan, 1969). Discriminant validity was assessed using the Marlowe-Crowne
Social Desirability Scale (Crowne & Marlowe, 1964).
The Community Attitudes to the Mentally 111 Scale (Appendix B)
(Taylor & Dear, 1981) is a 40-item scale designed as an update of the
Opinions of Mental Illness Scale (Cohen & Struening, 1962). The items are
presented in a 5-point Likert format (Strongly Agree, Agree, Neutral,
Disagree, Strongly Disagree), and are designed to assess attitudes regarding
mental illness. It includes four subscales: Authoritarianism (One of the
main causes of mental illness is a lack of self-discipline and will power);
Benevolence (The mentally ill have for too long been the subject of
ridicule); Social Restrictiveness (The mentally ill should not be given any
responsibility); and Community Mental Health Ideology (Residents should
accept the location of mental health facilities in their neighborhoods to serve
the needs of the local community). It was pilot-tested on a large sample of
20


an urban Toronto population to assess general community attitudes about
mental illness and persons with mental illness. In order to establish
convergent validity, the sample completed this scale as well as the AMMI.
It was hypothesized that persons scoring high on the CAMI Scale (indicating
more sympathetic attitudes regarding mental illness) would also score high
on the AMMI Scale (indicating more willingness to integrate the mentally ill
into community life). The magnitude of this positive correlation was
hypothesized to be moderate to high.
The Social Rejection Scale (Appendix C) (Trute & Loewen, 1978) is an 11-
item scale originally developed to assess whether public attitudes toward the
mentally ill are a function of direct experience with people with mental illness
(You would strongly discourage your children from marrying someone who had
been a patient in a psychiatric hospital). It is presented in a 5-point Likert format
(Strongly Agree, Agree, Undecided, Disagree, Strongly Disagree). It was originally
piloted on a sample of people living near openly identified sheltered care facilities
for persons with chronic disabilities caused by mental illness and who were ex-
patients of a psychiatric hospital. It is assumed that people with high scores on this
scale (indicating a need to maintain social distance between themselves and ex-
patients) would score low on the AMMI Scale, and therefore the Social Rejection
Scale will help establish convergent validity. It was hypothesized that the
21


correlation between the AMMI Scale and Social Rejection Scale scores will be
negative, and moderate in magnitude.
The Hogan Empathy Scale (Appendix D) (Hogan, 1969) was developed to
assess the disposition to adopt a broad moral perspective (Hogan, p. 307) or to
place oneself in the role of another. It consists of 61 items presented in a True/False
forced-choice format. Thirty-one of these items are taken from the California
Psychological Inventory, 25 of them are taken from the Minnesota Multiphasic
Personality Inventory, and eight are taken from archival research records from the
University of Californias Institute of Personality Assessment and Research (As a
rule I have little difficult in putting myself into other peoples shoes). It was
hypothesized that persons scoring high in empathy would be more willing to accept
integration of the mentally ill into community life. Therefore, the Empathy Scale
also helped establish convergent construct validity for the AMMI Scale, and the
magnitude of the expected positive correlation was hypothesized to be moderate.
The Marlowe-Crowne Social Desirability Scale (Appendix E) (Crowne &
Marlowe, 1964) assesses the tendency to present oneself in a socially desirable
manner (T never hesitate to go out of my way to help someone in trouble). It is a
3 3-item scale presented in a True/False forced-choice format. A scale that elicits a
desirability response set would be useless in assessing attitudes toward integrating
people with mental illness. The Social Desirability Scale was therefore be helpful in
22


providing discriminant validity evidence, and in order to do so, there should be a
low correlation between the Social Desirability Scale and the AMMI Scale.
Group validity was assessed by two methods. First, the undergraduate
subject pool was asked whether they, one of their family members or a close friend
had ever received treatment for a mental illness or had received any sort of mental
health services. The original (undergraduate) subject pool can therefore be divided
into two groups: those familiar with mental health issues (having received
themselves or had a family member or friend receive treatment) and those
unfamiliar (having no such history). Second, the AMMI scale was given to a group
of 30 mental health professionals. It was hypothesized that there would be a
significant difference in attitude toward integrating the mentally ill between the
three familiarity groups.
Forty-five undergraduate students were chosen to receive a second
administration of the AMMI Scale in order to assess its temporal stability via test-
retest reliability. This second administration took place three weeks after the initial
administration. Due to inadequate data received from the second administration, ten
of the retest scales could not be matched to the original administration. At the
original administration, subjects were directed to choose a symbol that they would
place on both the first and the second administration, thereby allowing correlation of
the administrations without sacrificing anonymity. Ten subjects failed to provide
symbols on their second AMMI Scale, and these were thus discarded, making a total
23


of 35 students who participated in the test-retest reliability aspect of scale
development. Results from the primary and secondary administrations of the
AMMI Scale were analyzed to establish test-retest reliability.
The sample of mental health professionals completed the AMMI Scale only.
24


CHAPTER 3
RESULTS
All data were analyzed using the Statistical Package for the Social Sciences
(SPSS version 9 for Windows). Missing or ambiguously answered data were
handled according to the nature of the data. On the AMMI, CAMI and the Social
Rejection Scales, if a subject responded with two answers (i.e., Strongly Agree and
Agree) for an item, the subject was given the mean score for those two answers (i.e.
6.5). On the MCDSC and the Empathy Scale, if a subject responded with both
answers (true and false) for an item, the subjects answer for that item was
eliminated from the data set. If the subject failed to respond to an item on any scale,
the subject received no score for that particular item. The number of subjects
ensured that this treatment did not reduce the validity of the data analysis.
Item Analysis
Item validity was assessed using item/total correlations and item/criterion
correlations. The first method correlates each individual AMMI item score with the
total score on the AMMI Scale, and is a way to assess the construct validity of each
item. A higher correlation indicates better validity; that is, the item is strongly
related to the construct measured by the scale. Item/total correlations for the AMMI
25


Scale items are presented in Table 3.1. With the exception of Item 9 (I would not
feel comfortable working with a person with a mental illness on a class project), all
item/total correlations are significant and within or above the desired range of .30 to
.60, which would indicate that the items have moderately high construct validity.
Item 9 has no significant correlation with the AMMI Scale.
Item/criterion correlations were also computed in order to establish construct
validity by assessing the relationships between individual scale items and the total
scores on the criterion scales. Correlations between the AMMI Scale items and the
scores for scales utilized to establish convergent and discriminant validity are
presented in Table 3.2. As with the item/total correlations, all are significant except
for correlations for Item 9, once again indicating that this item has weak construct
validity.
Item 7 shows the strongest correlation with the MCSDS, and therefore the
item most contaminated by the social desirability response set. The content of this
item appears to assess two constructs, both the willingness to integrate the mentally
ill into community life and the willingness to become involved in a community
organization (T would join a neighborhood or community organization that had
people with mental illnesses as members). The inclusion of the second construct
might be the source of the contamination, or the two constructs could interact to
create the contamination. Regardless of the reason, based upon the above item
26


Table 3.1
Item/total correlations for the AMMI Scale
Item AMMI Total N= 173
1 .369
2 .399
3 .609
4 .565
5 .642
6 .650
7 .638
8 .677
9* .171
10 .605
11 .576
12 .626
13 .468
14 .659
15 .658
16 .788
17 .757
18 .735
19 .641
20 .711
21 .715
22 .528
23 .507
^indicates item with lowest correlation
Item AMMI Total N= 173
24 .503
25 .516
26 .523
27 .703
28 .741
29 .664
30 .439
31 .598
32 .689
33 .653
34 .521
35 .551
36 .646
37 .621
38 .445
39 .580
40 .553
41 .530
42 .639
43 .539
44 .360
45 .504
46 .524
47 . 815
AMMI = Attitudes toward Mainstreaming the Mentally 111 Scale
27


Table 3.2
Item/criterion correlations between each AMMI Scale item and the validity scales
(CAML Social Rejection Scale. Social Desirability Scale. Empathy)
Item SR Total CAMI Auth CAM Ben CAM SR CAM CMH CAM Total MCSDS Total Empathy Total
1 R -.273 .299 .381 .283 .275 .364 .087** .105**
N 172 171 171 171 170 172 172 172
2 R -.350 .237 .186* .327 .276 .301 .051** .134**
N 173 172 172 172 171 173 173 173
3 R -.473 .398. .350 .471 .398 .479 .033** .025**
N 173 172 172 172 171 173 173 173
4 R -.511 .422 .322 .477 .423 .481 .032** .064**
N 173 172 172 172 171 173 173 173
5 R -.519 .362 .337 .512 .474 .501 .088** .155*
N 173 172 172 172 171 173 173 173
6 R -.441 .358 .429 .493 .417 .504 .159* .279*
N 173 172 172 172 171 173 173 173
7 R -.501 .366 .438 .444 .421 .494 .292 .273
N 173 172 172 172 171 173 173 173
8 R -.545 .481 .442 .498 .457 .547 .166* .086
N 173 172 172 172 171 173 173 173
9 R -.050** -.056** -.046** .017** .021** -.014** -.070** 012**
N 173 172 172 172 171 173 173 173
10 R -.480 .303 .257 .399 .339 .383 .175* .025**
N 173 172 172 172 171 173 173 173
11 R -.467 .316 .271 .416 .372 .404 .002** -.015**
N 173 172 172 172 171 173 173 173
12 R -.574 .356 .350 .479 .422 .482 .195* 147**
N 173 172 172 172 171 173 173 173
13 R -360 .254 .210 .337 .298 .332 .002** .033**
N 173 172 172 172 171 173 173 173
14 R -.596 .393 .314 .510 .424 .488 .164* .044**
N 173 172 172 172 171 173 173 173
15 R -.552 .376 .292 .482 .478 .484 .029** .073**
N 173 172 172 172 171 .173 173 173
16 R -.646 .482 .468 .595 .541 .611 .162* .139**
N 173 172 172 172 171 173 173 173
17 R -.586 .448 .492 .558 .507 .591 147** .138**
N 173 172 172 172 171 173 173 173
28


Table 3,2 (cont.)
Item SR Total CAMI Auth CAMI Ben CAMI SR CAMI CMHI CAMI Total MCSDS Total Empathy Total
18 R -.641 .447 .454 .575 .498 .580 .179* .066**
N 173 172 172 172 171 173 173 173
19 R -.481 .378 .469 .503 .408 .516 .108** .161*
N 173 172 172 172 171 173 173 173
20 R -.601 .443 .390 .557 .464 .547 .084** .196*
N 173 172 172 172 171 173 173 173
21 R -.584 .509 .397 .579 .501 .580 .069** .049**
N 173 172 172 172 171 173 173 173
22 R -.361 .345 .343 .374 .326 .406 .106** .164*
N 171 170 170 170 169 171 171 171
23 R -316 .277 .374 .358 .370 .404 .118 .032**
N 172 171 171 171 170 172 172 172
24 R -.332 .293 .334 .292 .293 .335 .134** .094**
N 172 171 171 171 170 172 172 172
25 R -.463 .262 .331 .417 .410 .421 .188* .125**
N 172 171 171 171 170 172 172 172
26 R -.449 .266 .313 .407 .337 .392 .017** .055**
N 172 171 171 171 170 172 172 172
27 R -.467 .421 .371 .524 .408 .506 .074** .100**
N 172 171 171 171 170 172 172 172
28 R -.533 .424 .373 .513 .474 .525 .070** .000**
N 172 171 171 171 170 172 172 172
29 R -.555 .465 .369 .588 .612 .600 .057** -.065**
N 172 171 171 171 170 172 172 172
30 R -.347 .278 .240 .293 .232 .303 .008** .073**
N 172 171 171 171 170 172 172 172
31 R -.425 .389 .284 .417 .344 .418 .014** .084**
N 172 171 171 171 170 172 172 172
32 R -.518 .379 .290 .463 .440 .461 .041** -.013**
N 172 171 171 171 170 172 172 172
33 R -.561 .420 .349 .531 .441 .515 .148** .114**
N 172 171 171 171 170 172 172 172
34 R -.430 .305 .321 .450 .420 .441 .156* .087**
N 172 171 171 171 170 172 172 172
35 R -.440 .436 .234 .462 .483 .477 .148** .073**
N 171 170 170 170 169 171 171 171
36 R -.458 .438 .368 .518 .407 .505 .120**
N 172 171 171 171 170 172 172 172
37 R -.453 .491 .366 .563 .458 .549 .033** .036**
N 172 171 171 171 170 172 172 172
38 R -.312 .261 .263 .355 .322 .353 .135** -.007**
N 172 171 171 171 170 172 172 172
39 R -.423 .369 .392 .470 .481 .504 .146** .005**
N 172 171 171 171 170 172 172 172
29


Table 3.2 (cont.)
Item SR Total CAMI Auth CAMI Ben CAMI SR CAMI CMHI CAMI Total MCSDS Total Empathy Tothl
40 R -.386 .327 .298 .438 .357 .420 .156** .168**
N 172 171 171 171 170 172 172 172
41 R -.342 .349 .331 .492 .384 .454 .065** .010**
N 172 171 171 171 170 172 172 172
42 R -.468 .479 .403 .653 .517 .598 .034** .009**
N 172 171 171 171 170 172 172 172
43 R -.381 .401 .381 .451 .372 .469 .107** -.062**
N 172 171 171 171 170 172 172 172
44 R -.319 .297 .079** .365 .255 .293 .034** .044**
N 172 171 171 171 170 172 172 172
45 R -.441 .378 .276 .449 .454 .459 -.004** .101**
N 172 171 171 171 170 172 172 172
46 R -.359 .412 .411 .464 .367 .488 -.057** .226
N 172 171 171 171 170 172 172 172
47 R -.594 .423 .449 .565 .540 .581 .167* .138**
N 172 171 171 171 170 172 172 172
SR = Social Rejection Scale
CAMI Community Attitudes toward the Mentally 111 Scale
CAMI Auth. = CAMI Authoritarian subscale
CAMI Ben. = CAMI Benevolence subscale
CAMI SR. = CAMI Social Restrictiveness subscale
CAMI CMHI = CAMI Community Mental Health Ideology subscale
Empathy = Hogans Empathy Scale
MC = Marlowe-Crowne Social Desirability Scale
Unstarred correlations are significant at the .01 level
Single starred correlations are significant at the .05 level.
Double starred correlations are non-significant.
30


analysis, Items 7 and 9 were determined to have weak construct and discriminant
validity and were removed from the AMMI Scale.
Factor Analysis
To explore the possible factor structure of the AMMI Scale, responses to the
remaining 45 items were subjected to a principal components factor analysis with a
Varimax rotation.
The initial Scree Test (Cattell, 1962), which uses criteria based on the
magnitude of eigenvalues identified a strong single factor with an eigenvalue of
17.396, accounting for 39.29% of total variance. Eight weaker factors accounting
for another 25.6% of the variance were also identified. The nine factors rotated and
extracted during initial factor analysis accounted for 64.89% of the total variance.
Perusal of the resulting nine factor solutions showed that the vast majority of items
loaded onto multiple factors, making the factors difficult, if not impossible, to
interpret.
Additional factor analysis rotations were performed in order to see if a more
interpretable solution could be found. Extraction of two factors and three factors
produced similar results. No discernible pattern or theme could be determined for
the items loading on each factor for either analysis, and most items loaded onto
multiple factors. Thus, it appears that the AMMI Scale is best treated as a
unidimensional scale.
31


Normative Data
It was first necessary to determine whether the two pilot samples (from the
University of Colorado at Denver and from Front Range Community College)
differed significantly in terms of their scores on the AMMI Scale. The mean scores
for the AMMI Scale for the two undergraduate samples are presented in Table 3.3.
A t-test for independent samples determined that the two groups did not differ
significantly (t = -.766, df= 171) and therefore the college sample data were pooled
for subsequent analysis.
Table 3.3
Normative Data for college sample, separated bv location.
Scale UCD FRCC
AMMI Total Mean 241.49 246.53
Std. Dev. 38.86 42.44
N 128 45
Means and standard deviations for the total pooled college sample and for
the sample broken down by gender are presented in Table 3.4. There were
significant differences in AMMI scores between gender (t = -2.392, p = .018, df=
169).
32


Table 3.4
Normative data for college sample as a whole, and separated by gender
Scale College Female Male
AMMI Total Mean 230.54 236.11 221.54
Std. Dev. 38.75 36.16 39.85
N 173 115 56
Scores of women were higher than those of men, indicating more willingness to
integrate persons with mental illnesses into community life. There was no
significant gender difference in the professional sample (t = -1.588, df = 28)..
Means and standard deviations for the validation scales (CAMI Scale and subscales,
Empathy Scale, Social Rejection Scale and MCSDS) are presented in Table 3.5.
The data for these scales are also broken out by gender. There were significant
differences between genders for the CAMI Authoritarian subscale (t = -2.674, p =
.009, df= 169); CAMI Benevolence subscale (t = -2.593, p. .011, df = 168); CAMI
- Social Restrictiveness subscale (t = -2.298, p = .023, df = 168); and CAMI Scale (t
= -2.663, p. = .009, df = 169). Again, the scores for females were higher than for
males, indicating more positive attitudes toward people with mental illnesses among
females than among males. There were no significant differences between genders
on the CAMI Community Mental Health Ideology subscale (t = -1.676, df = 167),
the Social Rejection Scale (t = 1.562, df = 169), the Social Desirability Scale (t = -
.074, df = 169) or the Empathy Scale (t = -.488, df = 169).
33


Table 3.5
Normative Data for the validation scales for sample as a whole and separated by
gender
Scale College Female Male
CAMI Total Mean 145.15 148.00 140.06
Std. Dev. 17.87 16.70 19.02
N 173 115 56
CAMI Auth Mean 35.99 36.64 34.69
Std. Dev. 4.50 4.38 4.50
N 172 115 56
CAMI Ben Mean 37.92 38.75 35.45
Std. Dev. 5.03 4.34 5.93
N 172 115 56
CAMI SR Mean 36.83 37.56 35.58
Std. Dev. 5.47 5.49 5.11
N 172 115 55
CAMI CMHI Mean 34.58 35.14 33.52
Std. Dev. 5.90 5.75 6.19
N 171 114 55
SR-Total Mean 28.90 28.23 30.16
Std. Dev. 7.59 7.65 4.51
N 173 115 56
Empathy Mean 33.31 33.56 33.11
Std. Dev. 5.80 5.20 6.50
N 173 115 56
MC Total Mean 15.59 15.56 15.5
Std. Dev. 5.05 4.93 5.18
N 173 115 56
SR = Social Rejection Scale
CAMI = Community Attitudes toward the Mentally 111 Scale
CAM! Auth. = CAMI Authoritarian subscale
CAM! Ben. = CAMI Benevolence subscale
CAMI SR. = CAMI Social Restrictiveness subscale
CAMI CMHI = CAMI Community Mental Health Ideology
subscale
MC = Marlowe-Crowne Social Desirability Scale
Empathy = Hogans Empathy Scale
34


Reliability
Internal reliability was assessed using Cronbachs Coefficient Alpha in order
to determine if all the items were measuring the scale construct. The analysis of the
original 47 AMMI Scale items revealed strong internal consistency, = .95 (p
<001). Elimination of weak Items 7 and 9 raised alpha to .96 (p<001). These high
alphas provide further support that the AMMI is unidimensional.
Test-retest reliability was established by correlating responses on the
original administration of the AMMI Scale with responses to the administration
three weeks later. Analysis revealed solid temporal stability (r = .860 (n = 35, p <
.01). It is apparent that the AMMI Scale measures a reasonably stable construct
and that the scale items are all measuring the same thing.
Validity
Construct Validity
Convergent and discriminant validity data are presented in Table 3.6.
Convergent validity was explored by correlating scores between the AMMI Scale
and subscales (with Items 7 and 9 removed) and the CAMI (total and subscales),
Empathy, and Social Rejection Scales. Discriminant validity was explored by
35


correlating scores between the AMMI Scale and the Marlowe-Crowne Social
Desirabihty Scale.
Table 3.6
Convergent and discriminant validity data
SR Auth Ben SR CMHI CAMI MCSDS Empathy
AAMI Scale R -.746 .605 .549 .770 .662 .762 .140** .124**
N 173 172 172 172 171 173 173 173
Unstarred correlations are significant at the .01 level
Single starred correlations are significant at the .05 level
Double starred correlations are non-significant.
AMMI = Attitudes toward Mainstreaming the Mentally HI Scale
SR = Social Rejection Scale
Auth. = CAMI Authoritarian subscale
Ben. = CAMI Benevolence subscale
SR. = CAMI Social Restrictiveness subscale
CMEU = CAMI Community Mental Health Ideology subscale
CAMI = Community Attitudes toward the Mentally HI Scale
MC = Marlowe-Crowne Social Desirabihty Scale
Empathy = Hogans Empathy Scale
There were significant and strong negative correlations between the AMMI
Scale and the Social Rejection Scale (r = -.746, p < .01). This supports the
hypothesis that a greater willingness to integrate people with mental illness is
related to a reluctance to maintain social distance from such people. There were
significant and strong positive correlations between the AMMI Scale and the CAMI
Scale (r = .762, p < .01) and its Authoritarian (r = .605, p < .01), Benevolence (r =
.549, p < .01), Social Restrictiveness (r = .770, p < .01) and Community Mental
Health Ideology (r = .662, p < .01) subscales. These results support the hypothesis
that people with positive attitudes regarding mental illness in general expressed a
36


greater willingness to integrate the mentally ill into community life. Both of these
correlations provide evidence that the AMMI Scale measures a construct similar to
those being measured by the CAMI and the Social Rejection Scale. There were no
significant correlations between the AMMI Scale and the Social Desirability Scale
(r = .140, p = ns), indicating little contamination from a social desirability response
set. The hypothesized significant correlation between the AMMI Scale and the
Empathy Scale did not materialize (r = 124, p = ns). This indicates that empathy as
measured by the Hogan Empathy Scale is not related to a willingness to integrate
people with mental illnesses into the community. However, it is possible that
empathy and the construct measured by the AMMI Scale are related but that the
large inequality in sample size (173 in the unfamiliar group and 30 in the familiar
group) masked the relationships.
Group validity
Normative data for the AMMI Scale broken down by familiarity groups is
contained in Table 3.7.
Table 3.7
Normative data separated bv familiarity group
SCALE Familiar Unfamiliar MH Worker
AMMI Total Mean 238.29 221.31 229.67
Std Dev. 36.02 38.59 38.72
N 101 70 30
37


Group validity was established in two ways. First, the mean AMMI Scale scores for
college students and mental health workers were compared. Independent-samples t-
test revealed no significant difference between the two groups on the AMMI Scale
(t = -.114, df = 201, p = ns).
A second independent-samples t-test revealed significant differences
between the unfamiliar and familiar college groups on the AMMI Scale (t = -2.942,
df = 169, p = .004). People with some familiarity with mental health issues, either
through having received treatment themselves or having a close friend or family
member receive treatment, scored higher on the AMMI Scale than those without
this familiarity. This indicates that people who are familiar with mental health
issues display a greater willingness to integrate people with mental illnesses into the
community. Means and standard deviations for AMMI scores for each familiarity
group (familiar, unfamiliar, and mental health worker) are presented in Table 7.
38


CHAPTER 4
DISCUSSION
The AMMI Scale appears to be a reasonably sound unidimensional measure
of the identified construct. The 45 items remaining after item analysis showed
strong reliability and validity. The fact that the AMMI Scale proved to be
unidimensional suggests that people do not differ in their attitude about integrating
persons with mental illness as a function of social setting or distance (casual versus
intimate). Although this finding may appear inconsistent with earlier work using
the CAMI, in fact the CAMI Scale itself possesses a questionable and difficult-to-
replicate factor structure. Although Taylor and Dear (1981) identified four
underlying factors (the ones used in this thesis as convergent validity subscales),
subsequent research with the scale has identified several different factor structures.
Therefore, both scales seem to support the concept that attitudes toward the
mentally ill or toward integrating the mentally ill into community life is
unidimensional. This may actually be an advantage in using the AMMI Scale. A
sound unidimensional scale, with solid psychometric properties, is more efficient
and certainly more valuable than a scale with weak multi-dimensional properties. A
unidimensional scale results in one score rather than several, simplifying future data
39


analysis, and use of a weak multi-dimensional scale might lead to erroneous
conclusions in future research.
As hypothesized there was a positive correlation between the AMMI Scale
and the CAMI Scale. This finding supports the notion that those with more positive
attitudes toward mental illness in general have more positive attitudes toward
integrating the mentally ill into community settings. The strength of the correlations
between the AMMI Scale and the CAM! Scale indicate that, although the construct
measured by the AMMI Scale is more closely related to that measured by the CAMI
Scale than hypothesized, it is not measuring the identical construct, which would
have resulted in an even higher correlation. The high correlations between the
AMMI Scale and the Social Restrictiveness subscale of the CAMI are to be
expected, and suggest a willingness to integrate people with mental illness into
community settings and an aversion to an attitude of restrictiveness toward the same
population. A high negative correlation between the Social Rejection Scale and the
AMMI Scale was revealed, suggesting that persons with a positive attitude toward
integrating the mentally ill into community settings are less likely to distance
themselves socially from people with mental illnesses.
The hypothesized positive correlation between the Empathy Scale and the
AMMI scale did not materialize. This may be due to the fact that the Empathy
Scale was designed primarily as a measurement of role-taking ability. Role-taking
ability has been defined as the ability to understand anothers thinking or feeling -
40


that is, perceiving the world as the other person does (Gladstein, 1983). It may be
that this is too limited a definition of empathy for the purpose of this study.
Empathy has been conceptualized by some as having cognitive aspects such as
processes such as accurate perceptions of others and social competence (Gladstein;
Hogan, 1969). However, others have stated that empathy depends more strongly on
emotional reactivity (Davis, 1982) or emotional contagion, referring to a persons
emotional response while observing anothers actual or anticipated condition
(Gladstein) or an other-oriented emotional response (Batson, et al., 1988). Role-
taking ability appears to be a cognitive process, depending on the intellectual ability
to place oneself in the position of another and the ability to mentally comprehend
their perspective. Therefore, a scale designed to measure both the cognitive and
emotional aspects of empathy (or perhaps measuring the emotional aspects alone)
might reveal a correlation between this concept of empathy and the willingness to
integrate the mentally ill into community life.
The significant differences in gender for the AMMI Scale mirror differences
found in previous research with the CAMI Scale, with females showing more
acceptance of those with mental illnesses. This finding could be explained by
looking at the differences between men and women on a variety of measures.
Women are more empathic than men (Hogan, 1969), and tend to define themselves
in terms of their relationships to others (Gilligan, 1982) which would create more
41


acceptance of people who are different in some way. These gender findings provide
some additional support for the construct validity of the AMMI.
Interestingly, the mental health worker sample showed no greater
willingness to accept persons with mental illnesses in the community than did the
college sample. Although it is true that research has shown that even professional
people tend to have negative attitudes regarding the mentally ill, these attitudes have
on the whole been less negative than laypersons. Therefore, it was expected that
that people with greater familiarity with mental health issues due to work in the field
would show a greater acceptance toward others with mental illnesses. The large
disparity in sample size between college students (N = 173) and mental health
workers (N = 30) could explain this unexpected finding, as such a disparity could
mask any difference that exists. However, it is also possible that working closely
with the mentally ill may produce burnout or the wish to avoid living with the
population with whom you work. Another possible explanation for this finding is
that the type of mental health worker sampled is highly specialized. Employees of
Aurora Community Mental Health Center work primarily with persons who are too
low-functioning to maintain gainful employment or maintain themselves in the
community without significant and ongoing support. Persons who work with these
clients might suffer from what has been termed clinician bias, that is, a tendency
to lead clinicians to underestimate clients abilities and overestimate clients illness
(Harding, Zubin & Strauss, 1987). Clinician bias might lead those working with
42


this population to reject integration of the mentally ill into the community, or to be
less enthusiastic about such a concept than clinicians with a more heterogeneous
clientele. While these are speculations only, it would be appropriate in the future to
assess the opinions of people who work in other types of settings, in which there is a
wider range of client functioning, to continue to explore group validity for the
AMMI Scale.
There was a significant difference between the college students who reported
familiarity and those who did not. The fact that familiarity groups in the college
sample were significantly different does establish some measure of group validity
for the AMMI Scale. Although an examination of the mean AMMI Scores for all
familiarity groups (college familiar, college unfamiliar, and mental health worker)
reveals that the means are in the expected directions, with unfamiliar college
students scoring lowest, this failure to find a difference in scores between college
students and mental health workers requires further exploration.
The results of this study support the validity and potential utility of the
AMMI. However, additional research is needed to explore further the construct
validity of the scale. It would be useful to examine the AMMI Scales relationship
to such constructs as community-mindedness or identification with community,
tolerance for diversity, fear of violence, volunteerism, or religiosity. Community-
mindedness and identification with a community (also called community
cohesiveness) has been negatively associated with acceptance of community
43


treatment; people with a strong sense of community expressed reluctance to accept
people with mental illnesses into the community. Tolerance for diversity and
volunteerism are hypothesized to be positively correlated with willingness to
integrate the mentally ill into community life, while fear of violence would be
expected to be negatively correlated. Religiosity has been shown to be differently
correlated with attitudes toward the mentally ill: some studies have found that the
type of religion plays a part in the differential attitudes toward people with mental
illness, and others have found that more regular religious service attendance is
negatively correlated with attitudes toward the mentally ill. The results of these
correlations would help in providing additional support for the construct validity of
the AMMI Scale.
It will also be necessary to test the AMMI Scale using more diverse
community samples. Previous research has indicated that demographic variables
such as marital status, socioeconomic status or ethnicity are correlated with
significant differences on the CAMI Scale and the Social Rejection Scale.
Replication of these results with the AMMI Scale would go a long way to provide
additional evidence for the group validity of the scale. In addition, these results
could be used to identify possible acceptor or rejector neighborhoods, based on
demographic make-up.
Finally, studies of predictive validity are needed. For example, it would be
interesting to give the AMMI Scale to those in a neighborhood targeted for
44


placement of a group home. Follow-up with this same neighborhood to see if initial
AMMI Scale scores (whether positive or negative) predicted actual community
reaction would be invaluable. Studies such as these will help to refine the AMMI
and should make it useful for a number of applied purposes, such as identifying
acceptor or rejector neighborhoods. It remains to be seen, however, whether
communities that indicate a willingness to integrate the mentally ill would actually
behave in ways congruent with their answers on standardized scales of this type. In
spite of the low social desirability contamination of the AMMI Scale, there is a
good possibility that neighborhoods who score high on the scale would behave in
ways that are incongruent with their scores. The not in my backyard effect, where
communities express an unwillingness to accept in practice those things that they
support in principle, is a reality with which most non-profit agencies must cope;
therefore, only future research with the AMMI Scale will provide evidence of its
practical use. No paper-and-pencil test can fully take the place of actual behavioral
observation; however, a test that highly predicts future behavior would be
invaluable in streamlining the process of integrating community-based treatment
facilities.
Another use for the AMMI Scale would be the measurement of attitudinal
change resulting from having the mentally ill integrated into the community, by
administering the scale before and after integration and comparing the results.
There have been a number of attempts to determine exactly what types of
45


information can alleviate fears regarding the mentally ill, and increase the likelihood
that the mentally ill will be welcomed (e.g., Peterson, 1986; Wahl & Lefkowitx,
1989; Wolff, Pathare, Craig, & Lefif, 1996c). The use of the AMMI Scale would
allow people planning these educational programs to identify the exact information
needed. For example, attitudes about mental illness in general might be made more
positive by the presentation of information about the biological nature of most major
mental illnesses, or about the purposes and successes of psychosocial rehabilitation,
or the desires of the mentally ill to live normal lives. The willingness to actually
welcome (or at least tolerate) the mentally ill in communities might be increased by
very different information, such as statistics regarding the actual versus perceived
violence of the mentally ill, the stereotypes perpetuated by the media regarding the
mentally ill (e.g., Wahl, 1995), or the lack of a decrease in property values in those
neighborhoods that have integrated community-based treatment. Use of the AMMI
Scale would be a way to identify which specific types of educational information
would most increase willingness to integrate the mentally ill into the community, as
the items are designed to measure that construct, which in theory is susceptible to
modification.
The AMMI Scale also has some potential theoretical utility. Use of the scale
with culturally different populations would assist in exploring differing attitudes
about mental illness in general as well as the integration of the mentally ill into the
community. The scale could also measure the difference in attitudes between
46


neighborhoods that do not have a group home and neighborhoods that do, with
contact hypothesized as increasing willingess to integrate the mentally ill. The scale
could also identify acceptor and rejector neighborhoods that have a group home or a
community treatment facility located in them, and then compare the experiences and
recovery progress of people with mental illnesses in each type of neighborhood.
This latter application would assist in establishing the importance of community
contact in the recovery process of people with mental illness. The AMMI Scale
could also be used to identify which neighborhoods would be most accepting of
which types of persons with mental illness. For example, communities might differ
on the acceptance of the mentally ill based on the type of behavior exhibited by the
patient, or by the label placed on the patient. By varying the presentation of the
definition of mental illness originally provided with the AMMI Scale, hypothesized
differences in level of willingness to integrate the mentally ill could be explored
both as a whole and as a function of community type.
In the future, the AMMI Scale might be useful after adaptation to other types
of community-based treatment. Group homes for adolescents and for sex offenders
meet the same resistance against community placement as do treatment options for
the mentally ill. The AMMI Scale could be modified to assess neighborhood
reaction to these populations, as well as for populations such as adults released from
correctional facilities.
47


CHAPTER 5
SUMMARY
A measurement to assess attitudes toward integrating the mentally ill into
community settings was developed. The AMMT Scale appears to be
unidimensional, and has solid internal and temporal reliability. Convergent and
discriminant validity were acceptable, but future research should continue to explore
this aspect of the scale as well as establish group and predictive validity. In
conclusion, it appears that the AMMI Scale is a potentially useful tool for use in
determining willingness to integrate people with mental illnesses into the
community, with future applications ranging from identifying which communities
will accept the mentally ill to determining what information assists people in
developing a more positive attitude toward such integration.
48


APPENDIX A
The Attitudes toward Mainstreaming the Mentally 111 Scale
1. Communities owe people with mental illnesses as much social support as other
people living in the community (for example, elderly people)
2. I would feel uncomfortable if people with mental illnesses were admitted to this
university
3. I think a company should hire qualified people, even if they have a mental
illness
4. I would feel uncomfortable doing business with a company that hired people
with mental illnesses
5. I would have no problems taking a business trip with a work colleague with a
mental illness
6. I would introduce myself to a new neighbor who had a mental illness.
7. I would join a neighborhood or community organization that had people with
mental illnesses as members
8. I would lend something to a neighbor who had a mental illness
9. I would not feel comfortable working with a person with mental illness on a
class project
49


10.1 would not invite a neighbor with a mental illness to a party in my house.
11.1 would not mind working in the same company or business as a person with a
mental illness
12.1 would not share an apartment with a person with mental illness
13.1 would feel uncomfortable taking a class taught by a person with a mental
illness.
14.1 would not want a boss with a mental illness
15.1 would not want a child with mental illness in the same classroom as my child
16.1 would not want to be in a study group with a person with a mental illness.
17.1 would not want to work directly with a person with mental illness
18.1 would refuse to work on a project one-on-one with a person with a mental
illness
19.1 would try getting to know a neighbor over coffee, even if he or she had a
mental illness
20.1 would use a tutor who had a mental illness.
21.1 wouldnt mind working on the same shift as a person with a mental illness
50


22. If a person with a mental illness lived in my neighborhood, I would put extra
locks on my doors.
23. If a person with a mental illness waited on me in a restaurant, I would feel
uncomfortable.
24. If I saw that my neighbor with a mental illness needed help with something (for
example, bringing in groceries), I would help him or her.
25. If I were responsible for renting apartments in a building I owned, I would not
hesitate to rent living quarters to someone with a mental illness.
26. If my professor were a person with a mental illness, I would hesitate to go to
his/her office hours for help.
27. It would be okay for a company to hire people with mental illnesses for
customer service positions
28. It would make me nervous to have a person with mental illness in my work
space
29. It would make me uncomfortable to have a person with a mental illness living in
my community.
30. It would not bother me to have a person with a mental illness in one of my
classes at school.
51


31. It would not bother me to have an employee or a subordinate someone who
reported to me be a person with a mental illness
32. My boss should not hire people with mental illnesses
33. My childs teacher should not be someone with a mental illness
34. Neighborhoods and mental health workers should work together to make sure
that people with mental illnesses can live in community settings
35. People with mental illnesses are more dangerous in the community than other
people.
36. People with mental illnesses can be good instructors
37. People with mental illnesses cannot be trusted to maintain themselves in
normal housing situations.
38. People with mental illnesses should be allowed to attend whatever classes at this
university that they want to attend.
39. People with mental illnesses should have special classes away from normal
students.
40. People with mental illnesses should not have children
41. People with mental illnesses should not many.
52


42. People with mental illnesses should only live in group homes or boarding homes
that are clearly identified to the public.
43. People with mental illnesses who are admitted to school should not get
scholarships.
44. People with mental illnesses who are living on their own should be required by
law to receive treatment.
45. People with mental illnesses who have violent histories or criminal records
should not be allowed to live in my community.
46. People with mental illnesses would be better off in jobs that involved little
public interaction.
47. Sharing an office with a person with mental illness would make me
uncomfortable.
53


APPENDIX B
The Community Attitudes to the Mentally 111 Scale
1. One of the main causes of mental illness is a lack of self-discipline and will
power.
2. The mentally ill have for too long been the subject of ridicule.
3. The mentally ill should be not given any responsibility.
4. Residents should accept the location of mental health facilities in their
neighborhoods to serve the needs of the local community.
5. The best way to handle the mentally ill is to keep them behind locked doors.
6. More tax money should be spent on the care and treatment of the mentally ill.
7. The mentally ill should be isolated from the rest of the community.
8. The best therapy for many mental patients is to be part of a normal community.
9. There is something about the mentally ill that makes it easy to tell them from
normal people.
54


10. We need to adopt a far more tolerant attitude toward the mentally ill in our
society.
11. A woman would be foolish to marry a man who has suffered from mental
illness, even though he seems fully recovered.
12. As far as possible, mental health services should be provided through
community-based facilities.
13. As soon as a person shows signs of mental disturbance, he should be
hospitalized.
14. Our mental hospitals seem more like prisons than like places where the mentally
ill can be cared for.
15.1 would not want to live next door to someone who has been mentally ill.
16. Locating mental health services in residential neighborhoods does not endanger
local residents.
17. Mental patients need the same kind of control and discipline as a young child.
18. We have a responsibility to provide the best possible care for the mentally ill.
19. Anyone with a history of mental problems should be excluded from taking
public office.
55


20. Residents have noting to fear from people coming into their neighborhood to
obtain mental health services.
21. Mental illness is an illness like any other.
22. The mentally ill dont deserve our sympathy.
23. The mentally ill should not be denied their individual rights.
24. Mental health facilities should be kept out of residential neighborhoods.
25. The mentally ill should not be treated as outcasts of society.
26. The mentally ill are a burden on society.
27. Mental patients should be encouraged to assume the responsibilities of normal
life.
28. Local residents have good reason to resist the location of mental health services
in their neighborhood.
29. Less emphasis should be placed on protecting the public from the mentally ill.
30. Increased spending on mental health services is a waste of tax dollars.
31. No one has the right to exclude the mentally ill from their neighborhood.
56


32. Having mental patients living within residential neighborhoods might be good
therapy but the risks to residents are too great.
33. Mental hospitals are an outdated means of treating the mentally ill.
34. There are sufficient existing services for the mentally ill.
35. The mentally ill are far less of a danger than most people suppose.
36. It is frightening to think of people with mental problems living in residential
neighborhoods.
37. Virtually anyone can become mentally ill.
38. It is best to avoid anyone who has mental problems.
39. Most women who were once patients in a mental hospital can be trusted as
baby-sitters.
40. Locating mental health facilities in a residential area downgrades the
neighborhood.
57


APPENDIX C
The Social Rejection Scale
1. You would strongly discourage your children from marrying someone who had
been a patient in a psychiatric hospital.
2. You would not resent the presence of a residence for discharged psychiatric
hospital patients in your area.
3. You would agree to providing board and room for a discharged psychiatric
patient in your home if you had room.
4. You would not object to a member of your family dating someone who had been
a patient in a psychiatric hospital.
5. You would not object to a group of discharged psychiatric patients renting or
buying an apartment or house on your street.
6. You can imagine yourself falling in love with someone who had been a patient in
a psychiatric hospital.
58


7. If the house next door was for sale, you would object to someone with a history
of psychiatric problems buying it.
8. If you were a manager and were responsible for hiring people to work for you,
you would be willing to hire a discharged psychiatric hospital patient.
9. You would welcome someone who had spent time in a psychiatric hospital to
take part in your community functions.
10. You would be willing to work on the same job with someone who had been a
patient in a psychiatric hospital.
11. If you were responsible for renting apartments in your building, you would not
hesitate to rent living quarters to someone known to have been in a psychiatric
hospital.
59


APPENDIX D
The Hogan Empathy Scale
The Hogan Empathy Scale consists of 61 items presented in a True/False
forced-choice format. Thirty-one of these items are taken from the California
Psychological Inventory and 25 are taken from the Minnesota Multiphasic
Personality Inventory. These items are under copyright and cannot be reproduced in
this format. Written permission to use these items follows. The remaining eight
items are:
1. As a rule I have little difficulty in putting myself into other peoples shoes.
2. I have seen some things so sad that I almost felt like crying.
3. Disobedience to the government is never justified.
4. It is the duty of a citizen to support his country, right or wrong.
5. Iam usually rather short-tempered with people who come around and bother me
with foolish questions.
6. I have a pretty clear idea of what I would try to impart to my students if I were a
teacher.
7. I enjoy the company of strong-willed people.
8. I frequently undertake more than I can accomplish.
60


APPENDIX E
Permission Letter from the University of Minnesota Press
for Research License
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APPENDIX E
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APPENDIX G
The Marlowe-Crowne Social Desirability Scale
1. Before voting I thoroughly investigate the qualifications of all the candidates.
2. I never hesitate to go out of my way to help someone in trouble.
3. It is sometimes hard for me to go on with my work if I am not encouraged.
4. I have never intensely disliked anyone.
5. On occasion I have had doubts about my ability to succeed in life.
6. I sometimes feel resentful when I dont get my way.
7. I am always careful about my manner of dress.
8. My table manners at home are as good as when I eat out in a restaurant.
9. If I could get into a movie without paying and be sure I was not seen, I would
probably do it.
10. On a few occasions, I have given up doing something because I thought too
little of my ability.
11. I like to gossip at times.
12. There have been times when I felt like rebelling against people in authority
even though I knew they were right.
13. No matter who Im talking to, Im always a good listener.
14. I can remember playing sick to get out of something.
64


15. There have been occasions when I took advantage of someone.
16. Im always willing to admit it when I make a mistake.
17. I always try to practice what I preach.
18. I dont find it particularly difficult to get along with loud mouthed, obnoxious
people.
19. I sometimes try to get even, rather than forgive and forget.
20. When I dont know something I dont mind admitting it.
21. Iam always courteous, even to people who are disagreeable.
22. At times I have really insisted on having things my own way.
23. There have been occasions when I felt like smashing things.
24. I would never think of letting someone else be punished for my wrongdoings.
25. I never resent being asked to return a favor.
26. I have never been irked when people expressed ideas very different from my
own.
27. I never make a long trip without checking the safety of my car.
28. There have been times when I was quite jealous of the good fortune of others.
29. I have almost never felt the urge to tell someone off.
30. Iam sometimes irritated by people who ask favors of me.
31. I have never felt that I was punished without cause.
32. I sometimes think when people have a misfortune they only got what they
deserved.
65


33. I have never deliberately said something that hurt someones feelings.
66


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