Opinions about mental illness in the personnel of two large mental hospitals

Journal vj Abnormal and Social J-'syo/wlogy1962, Vol. 64, No. 5, 349-360

OPINIONS ABOUT MENTAL ILLNESS IN THE PERSONNELOF TWO LARGE MENTAL HOSPITALS1

JACOB COHEN

New York University

ANU E. L. STRUENING

Montrose Veterans Administration Hospital

The past decade has witnessed several ma-jor shifts in the conception, care, and treat-ment of hospitalized mental patients. Therehas been a move toward "open" hospitals,milieu therapy, patient government, and pa-tient work programs. This newer outlook isbased on the general assumption that the well-being of mental patients is at least to someextent influenced by the social context. Deri-vations from this assumption include the morespecific hypotheses that mental patients aresensitive to and influenced by the attitudinalatmosphere created by hospital employees,that the success of reintegrating former men-tal patients into society is affected by the atti-tudes of the general public toward mental ill-ness, and that these attitudes play a role indetermining the support of mental health pro-grams by the general public as voters andtaxpayers.

Despite the manifest importance of thisarea, there has been little systematic researchdirected toward the finding of relationshipsbetween attitudes toward the mentally ill andsuch variables as symptom reduction, success-ful rehabilitation of former patients, hospitaldischarge rates, etc. Research of this kind de-pends upon the adequate conception and ob-jective measurement of attitudes toward men-tal illness and the mentally ill. The major

1 This work was carried out al the Franklin D.Roosevelt Veterans Administration Hospital, Mont-rose, New York, as part of the Veterans Administra-tion Psychiatric Evaluation Project, Richard L. Jen-kins, Director. We arc indebted to many VeteransAdministration personnel for their cooperation, amongthem L. L. Rackow, Manager; S. G. Klebanoff,Chief Psychologist; and Gloria Fischer, now at theUniversity of Oklahoma. We also wish to expressour gratitude to the IBM Watson Scientific Com-puting Laboratory, New York, for training us incomputer technology and giving us free access totheir facilities. Finally, we wish to express a con-tinuing sense of indebtedness to Catherine S. Hen-derson, the project secretary, and Ethel Haas, ourresearch assistant.

purpose of this investigation is to meet thisneed.

Previous work in this area is sparse. Thepioneer work was the development of theCustodial Mental Illness Ideology (CMI)Scale by Gilbert and Levinson (19S6). CMIscores were found to have correlates withhospital occupation, hospital treatment policy,and the California F Scale. The Cummings(19S7) developed a Guttman scale of socialdistance from mental patients for use in theircommunity studies. In both of these studies,a single (albeit different) pro-anti dimensionof attitude was conceived, appropriate itemswere written, and were found to "scale" inthe sense that internal consistency reliability(or reproducibility) was found to be ade-quate. But the fact that items can be organ-ized on a single dimension does not mean thatthey are best so organized. A ready analogycomes to mind from the area of human abil-ity. That one can identify a general intellec-tual factor in higher order domains (Thur-stone, 1947) does not deny the existence orusefulness of group factors (verbal, numeri-cal, space, etc.) in the understanding of intel-lectual functioning. The methodological basefrom which this investigation proceeds is thatopinions about the mentally ill are potentiallymultidimensional, and the number and natureof these dimensions is an empirical issue, andnot one to be assumed in advance; thus, thechoice of multiple-factor analysis.

We conceive of attitudes as inferred vari-ables which carry an affective or at least anadient-avoidant valence. Operationally, then,our responses reflect opinions, and the factorsderived therefrom may 2 represent attitudes.

The purpose of the investigation was two-fold:

2 But not necessarily. As will be noted later, Fac-tors A through D are understood to be attitudinalin this sense, while E is an opinion factor.

349

350 JACOB COHEN AND E. L. STKUENING

1. To identify and develop measures of thesalient dimensions underlying opinions aboutsevere mental illness among hospital per-sonnel.

2. To explore the construct validity of thesemeasures by relating them to demographiccharacteristics of the respondents—occupa-tion, education, age, and sex.

METHOD

Items. A pool of approximately 200 opinion itemsreferring to the cause, description, treatment, andprognosis of severe mental illness was prepared.These items were made up of quotations from caseconferences and casual conversations, and paraphrasesof ideas which arc current in the menial hospital.This group of items was reviewed by a group ofhospital experienced research workers,-'1 and itemswere edited, balanced with regard to pro and anticontent, and overlapping ones discarded until 55 re-rnained. These were supplemented by items (in somecases revised) from the Custodial Mental Illness Ide-ology (CMI) Scale (Gilbert & Levinson, 1956), theCalifornia F Scale (Struening, 1957), and Nunnally's(1957) work on popular conceptions of mental healthto form a 70-ilem set. AH items were presented inLikert format with provision following each for achecked response on a six-point agreement continuum.

Subjects. The phase of the investigation describedhere was carried out in two large Veterans Adminis-tration neuropsychiatric hospitals, one in the North-east (Hospital I) and another in the Midwest (Hos-pital II) and utilized as subjects large samples of thepersonnel in these two hospitals. Later tables (7 and8) give the distributions of these samples by occupa-tion, education, age, and sex. There were in all 541usable questionnaires from Hospital I and G53 fromHospital II, in each case broadly representative ofthe different levels and functions of personnel whosework brought them into frequent contact with thepatients. In each hospital, some two-thirds to three-quarters of the target population were obtained assubjects.

Administration. Most of the subjects in both hos-pitals were group tested so as to guarantee ano-nymity. Where this was not possible (e.g., nightnurses and aides who could not leave their posts),envelopes in which the completed questionnairescould be anonymously returned were provided. In-structions stressed anonymity and the fact that theissues were matters of opinion about which evenprofessionals differed, so that there were no right orwrong answers.

Data analysis. The method of analysis describedbelow was applied to each hospital separately. Thetwo sets of data were analyzed successively, and in

3 Seymour Slovik, Leonard Solomon, Herbert Spohn,Herbert Turkel, and Harold Wilcnsky participated inIhis phase of the work, for which we express ourindebtedness.

exactly the same way. First, the 70 X 70 matrix ofproduct-moment coefficients of correlation betweenindividual items was computed. Since the availableIBM 650 program for centroid factor extraction islimited to 40 X 40 matrices, the following strategemwas employed in analyzing the data for Hospital I:

1. The five items which yielded no more than onecorrelation numerically greater than .20 were droppedfrom further consideration.

2. Fifteen items whose correlations varied greatlyand would therefore be the nucleus of maximally in-dependent item clusters (Tryon, 1958, p. 12) wereselected as marker variables.

3. The remaining 50 items were randomly dividedin half and to each half the marker items were at-tached, yielding two 40 X 40 matrices sharing a groupof 15 marker items.

4. The two matrices were each subjected to astandard centroid factor analysis. The first five ccn-iroids* were rotated to an orthogonal, simple-struc-ture type of solution by means of the quartimax ana-lytic method (Neuhaus & Wrigley, 1954).

5. The two rotated factor matrices were then com-pared by reference to (lie 15 marker item loadings.They proved remarkably similar, and no difficultywas encountered in matching the five rotated factorsfrom the two analyses.

6. The factor matrices for the two analyses wen:then recombined. Since each marker item had twosets of loadings (one from each rotation in which itfigured), a single loading on each factor was ob-tained by determining the root mean square of thepaired loadings (i.e., the square root of the averageof the two squared loadings).

Exactly the same method was used to analyze theHospital II data. In Hospital II, 6 items weredropped completely on grounds of low correlationand 16 were used as marker items, resulting againin two 40 X 40 matrices of intercorrelations sharinga group of marker items which were analyzed asabove and recombined into a single factor matrix.

RESULTSFactors

As was the case in matching the factorsover the two 40 X 40 matrices within eaclihospital, no difficulty was encountered inmatching the five rotated factors in the twohospitals. As evidence of (he factor similaritybetween hospitals, for each factor separatelythe rotated factor loadings for the two hos-pitals were correlated over the 62 items which

4 There arc undoubtedly more than five commonfactors in each of the matrices, but starting with thesixth cenlroid, factor loadings do not exceed .30 andexceed .20 for only two or three items. Thus, the 5factors extracted arc deemed the most salient of aset of perhaps 15 (judging from the latent roots)common factors.

OPINIONS ABOUT MENTAL ILLNESS 351

TABLE 1FACTOR A—AUTHORITARIANISM

Loading

Hospital I

76

72

61

61

58

56

60

594752425853

49

58

435253

51

45

51

45

39

-72

Hospital II

61

53

55

49

51

54

47

495849553642

46

32

504035

38

41

23

39

40

06

Item

68. There is hardly anything lower than a person who does not feel a greatlove, gratitude, and respect for his parents.

65. Obedience and respect for authority arc the most important virtueschildren should learn.

11. When a person has a problem or worry, it is best not to think about it,but keep busy with more pleasant things.

34. A heart patient has just one thing wrong with him, while a mentally illperson is completely different from other patients.

16. All patients in mental hospitals should be prevented from having childrenby a painless operation.

26. There is something about mental patients that makes it easy to tellthem from normal people.

29. People with mental illness should never be treated in the same hospitalas people with physical illness.

14. Mental illness is usually caused by some disease of the nervous system.27. If people would talk less and work more, everybody would be better off.60. Every person should make a strong attempt to raise his social position.22. It is easy to recognize someone who once had a serious mental illness.12. Nervous breakdowns usually result when people work too hard.8. People who are mentally ill let their emotions control them; normal peoplethink things out.

52. Although patients discharged from mental hospitals may seem all right,they should not be allowed to marry.2. One of the main causes of mental illness is a lack of moral strength or willpower.

59. Every mental hospital should be surrounded by a high fence and guards.6. People would not become mentally ill if they avoided bad thoughts.

70. Every person should have complete faith in some supernatural powerwhose decisions he obeys without question.

31. A person who has bad manners, habits, and breeding can hardly expectto get along with decent people.

50. The best way to handle patients in mental hospitals is to keep them be-hind locked doors.

39. Although some mental patients seem all right, it is dangerous to forgetfor a moment that they are mentally ill.

66. College professors are more likely to become mentally ill than are businessmen.

24. Regardless of how you look at it, patients with severe mental illness areno longer really human.

13. The patients of a mental hospital should have something to say aboutthe way the hospital is run."

* Not in root mean square order because of inconsistency in loading.

appeared in both analyses. The resulting Pear-son correlations between hospitals are: A, .86;B, .73; C, .38; D, .60; E, .77. When the "un-adjusted correlation" (Burt, 1941,, p. 343) isused as an index of similarity, the resultingvalues are: A, .92; B, .62; C, .51; U, .61; E,.81. Using either criterion, the results, withthe possible exception of Factor C, are deemedsatisfactory.

The similarity of the factors between hos-pitals can be further judged by reference toTables 1 through 5, where the factor loadingsof both hospitals for the most highly loadeditems are presented. Tn each table, the items

are presented in decreasing order of their rootmean square loadings over the two hospitals(which are, however, not given) down to thelevel of .40 in Table 1 and about .30 inTables 2-S.5 Decimal points are omitted.Positive loadings indicate agreement, negativeloadings disagreement.

0 The only noteworthy inconsistency in loadingoccurs for Item 13 which loads Factor A heavily(—.72) in Hospital I and Factor C even moreheavily (.88) in Hospital II (Tables 1 and 3). Notethat this is not a logical inconsistency; the item fitsboth interpretations.

352 JACOB COHEN AND E. L. STRUENING

TABLK 2

FACTOR B—BENEVOLENCE

Loading

Ilonpiul II

44

-42

5130

-44--44

26

12

27

30

44

-41

3541

-26-07

37

43

34

29

28. ICven though patients in mental hospitals behave in funny ways, it iswrong to laugh about them.

54. There is little that can be clone for patients in a mental hospital exceptto sec that they are comfortable and well fed.

41. Anyone who tries hard to better himself'descrves the respect of others.37. Patients in mental hospitals arc in many ways like children.35. To become a patient in a mental hospital is to become a failure in life.42. Our mental hospitals seem more like prisons than like places where

mentally ill people can be cared for.4. Although they usually aren't aware of it, many people become mentallyill to avoid the difficult problems of everyday life.

38. More tax money should be spent in the care and treatment of people withsevere mental illness.

30. Although some mental patients seem all right, it is dangerous to forgetfor a moment that they arc mentally ill.

60. Kvcry person should make a strong attempt to raise his social position.

Factor A—-Authoritarianism. The concep-tion of mental patients projected by this fac-tor is one which stresses their difference fromand inferiority to normal people (Items 34,16, 26, 29, 22, 8, 52, 39, 24, and 13). Sev-eral items present popular (and contradic-tory) ideas about the causality of mental ill-ness (Items 14, 12, 2, 6, and 66).

This view of the mental patient exists in acontext which results in the five items (Items27, 31, 65, 68, and 70) taken from the Cali-fornia F Scale (Adorno, Frenkel-Brunswik,Levinson, & Sanford, 1950) having high load-ings on this factor; indeed, the two items giv-ing the largest loadings on Factor A are fromthe F Scale. These reflect the characteristicsubmission to authority (Items 65, 68, and 70)and "anti-intraceptiveness" (Items 11, 27, 6,and 66) of the authoritarian. In fact, Items6 and 66 indict thinking (bad or too much)as playing an etiological role in mental ill-ness. The handling of the hospitalized men-tally ill advocated here, namely, high fence,guards, locked doors (Items 59 and 50) bearsthe coercive authoritarian stamp.

We have named the common factor definedby the above elements Authoritarianism. Itpresents a gestalt made up of authoritariansubmission and anti-intraception with a viewof the mentally ill as a class inferior to nor-mals and requiring coercive handling. A mostinteresting possibility suggests itself that for

the authoritarian personality within the men-tal hospital, the mentally ill may function asa negatively stereotyped outgroup in muchthe same way as do racial, religious, or po-litical minority groups in the larger society.Indeed, Factor A is essentially identical withwhat the F Scale measures. This is demon-strated by the fact that the correlation be-tween Factor A scores based solely on itemshaving mental illness content (see below)with scores obtained by summing the 6 FScale items is .86, and exceeds unity whencorrected for attenuation.6

Factor A is a dominant factor which ac-counts for an average of 4-7% of the commonvariance in the two hospitals. This inciden-tally suggests that it is also essentially whatis measured by the CMI (Gilbert & Levin-son, 1956), since the total score obtained byadding together such items will be richlysaturated in the largest common factor run-ning through the item set, at the expense ofless extensive common factors. The substan-tial correlation between CMI and F was dem-onstrated by Gilbert and Levinson (1956).

Factor B—Benevolence. Factors B (Table

11 The role of acquiescence set in Factor A was notexplicitly studied. However, its importance cannotbe great in the light of the fact that in Hospital I,Item 13 gives rise to a negative loading of .72, i.e..those otherwise high on Factor A disagree with highconsistency with this item.

OPINIONS ABOUT MENTAL ILLNESS 353

2) and C (Table 3) are both "promental pa-tient," but they are so from rather differentperspectives, as evidenced by their near zeroshared variance (Table 6). The positive poleof B represents a benevolence toward patientswhich arises from a moral point of view, asort of Christian kindliness toward unfortu-nates. Mental patients are seen not as fail-ures in life (Item 35), but rather are likechildren (Item 37), and it is wrong to laughabout them (Item 28). Still, it is dangerousto forget for a moment that they are mentallyill (Item 39), a point of view which is alsopart of Factor A. They are looked upon asan obligation of society (Item 38), and morethan mere custodial care should be offeredthem (Item 54). Still, mental hospitals arenot like prisons (Item 42), in contrast withthe Factor C view. Finally, Items 41 and 60project the traditional value of self-improve-ment, which in this context suggests its ad-vocacy to mental patients (but note that Item60 also loaded Factor A). Factor B accountsfor an average of 15% of the variance sharedby the items.

In our earlier reports on this investigation(Cohen & Struening, 1959, 1960), we quali-fied "benevolence" by the adjective "unso-phisticated," which was not meant pejora-

tively, but intended to distinguish this factorfrom Factor C. Others close to our work haveresponded to other aspects of this factor andhave suggested such names as Parental Be-nevolence, Moral Benevolence, and Human-istic Benevolence. All these qualifiers can besupported by the item loadings. We have set-tled on the "common factor" of these inter-pretations, Benevolence, as the verbal tag toassign this factor. What is intended is akindly, paternalistic view towards patientswhose origin is in religion and humanismrather than a scientific or professional dogma.It is encouraging and nurturant, but still ac-knowledges some fear of patients. Furthersupport of this interpretation will be offeredin the later discussion of its demographic cor-relates.

Factor C—Mental Hygiene Ideology. Fac-tor C involves an orientation toward mentalpatients which is also positive, but embodiesthe tenets of the creed of modern mentalhealth professionals (Table 3). The itemshere are more factually descriptive of thementally ill; e.g., they are willing to work(Item 23), capable of skilled labor (Item 53),many would remain with unlocked doors(Item 55), ex-patients could be trusted asbaby sitters (Item 61), there is much mental

TABLE 3FACTOR C—MENTAL HYGIENE IDEOLOGY

Loading

Hospital I

48

45

26

40

39

3131

10

3714

Hospital II

25

28

3737

19

20

a

31

41

1688

Item

38. More tax money should be spent in the care and treatment of people withsevere mental illness.

44. If our hospitals had enough well trained doctors, nurses, and aides, manyof the patients would gel well enough to live outside the hospital.

23. Most mental patients are willing to work.61. Most women who were once patients in a mental hospital could be trusted

as baby sitters.53. Many mental patients are capable of skilled labor, even though in some

ways they are very disturbed mentally.25. Many people who have never been patients in a mental hospital are more

mentally ill than many hospitalized mental patients.69. The death penalty is inhuman and should be abolished.5.5. Many mental patients would remain in the hospital until they were well,

even if the doors were unlocked.42. Our mental hospitals seem more like prisons than like places where men-

tally ill people can be cared for.21. Mental illness is an illness like any other.13. The patients of a mental hospital should have something to say about the

way the hospital is run.b

11 Item omitted from the analysis.11 Not in root mean square order because of inconsisteney in loading.

354 JACOB COHEN AND E. L, STEUENING

illness outside of hospitals (Item 25) . Im-plicit in this conception is the idea that men-tal patients are much like normal people, dif-fering from them perhaps in degree, but notin kind, in sharp contrast with the FactorA orientation. This view is partially summa-rized in "Mental illness is an illness like anyother" (Item 21). The efficacy of treatmentis strongly believed in (Item 44), as is theassumption by society of its obligations to thementally ill (Item 38), the latter shared withFactor B. In contrast with Factor B, the itemlikening mental hospitals to prisons (Item 42)is endorsed here. Finally, opposition to thedeath penalty (Item 69) and advocacy of"hospital democracy" (Item 13) round outthe picture. Factor C accounts for an averageof 14% of the shared variance.

Because of the concordance of the elementsof Factor C with the tenets of the mentalhygiene movement, this factor was namedMental Hygiene Ideology. This interpretationis further supported by its correlation withoccupation and education (see below).

Factor D—Social Restrictiveness. Factor1), which accounts for an average over thetwo hospitals of 14% of the shared variance,emphasizes the desire to restrict mental pa-lienls both during and after hospitalization

for the protection of society, particularly thefamily unit (see Table 4). Thus, they shouldnot be allowed to marry after hospitalization(Item 52), should be easily divorced uponhospitalization (Item 48); indeed a woman"would be foolish" to marry an ex-mental pa-tient (Item 40). Their parental rights shouldalso be restricted by forbidding their smallchildren from visiting them (Item 20) andby sterilization (Item 16). Posthospital em-ployment as baby sitters should be closed tothem (Item 61). Mental patients should bedenied the right to vote (Item 57). All theseitems share the belief that mental illness is athreat to society which must be met by somerestriction in social functioning both duringand following hospitalization; Factor D wasaccordingly named Social Restrictiveness. Theother items loading this factor account forthe basis of the restrictive orientation. Thus,mental patients are seen as socially deficient;they do not care how they look (Item 64)and do not make wholesome friendships (Item51). Furthermore, the outlook for their fu-ture is hopeless: "There is little that can bedone" for them (Item 54)—they "Will neverbe their old selves again" (I tem 43).

One notes a certain similarity in outlookbetween Factor I) and Faclor A, and, in fact,

TABLE 4FACTOR D—SOCIAL RESTRICTIVENESS

Loading

Hospital I

49

45

36

13

35

-17

38

1816

-27

27

Hospital II

52

49

55

50

33

-42

22

3737

-29

Hem

40. A woman would be foolish to marry a man who has had a severe mentalillness, even though he seems fully recovered.

52. Although patients discharged from mental hospitals may seem all right,they should not be allowed to marry.

43. People who have been patients in a mental hospital will never be theirold selves again.

54. There is little that can be done for patients in a mental hospital exceptto see that they are comfortable and well fed.

48. The law should allow a woman to divorce her husband as soon as he hasbeen confined in a mental hospital with a severe mental illness.

61. Most women who were once patients in a mental hopsital could be trustedas baby sitters.

20. The small children of patients in mental hospitals should not be allowedto visit them.

64. Most patients in mental hospitals don't care how they look.16. All patients in mental hospitals should be prevented from having children

by a painless operation.51. Many patients in mental hospitals make wholesome friendships with

other patients.57. Anyone who is in a hospital for a mental illness should not be allowed to

vote.

OPINIONS ABOUT MENTAL ILLNESS 355

TABLE 5

I1'ACTOR E—INTERPERSONAL ETIOLOGY

56

53

5240

35

32

27

Loa

il I

ling

Hospital II

48

47

4730

23

25

28

Item

3. Mental patients come from homes where the parents took little interest intheir children.

5. The mental illness of many people is caused by the separation or divorceof their parents during childhood.

1. If parents loved their children more, there would be less mental illness.9. If the children of mentally ill parents were raised by normal parents, they

would probably not become mentally ill.33. If the children of normal parents were raised by mentally ill parents, they

would probably become mentally ill.4. Although they usually aren't aware of it, many people become mentally

ill to avoid the difficult problems of everyday life.67. People who are successful in their work seldom become mentally ill.

inspection of the graphed factor plots indi-cates that were the rotation oblique, therewould be some correlation between A and D(see Table 6 and discussion below). Thesetwo factors are nevertheless distinct with theemphasis of restrictiveness to protect thefamily the distinguishing feature.

Factor E—Interpersonal Etiology. FactorK is highly specific in its reference and highlyconsistent between the two hospitals (seeTable 5). Its positive pole reflects quitestrongly a belief that mental illness arisesfrom interpersonal experience, particularlydeprivation of parental love and attentionduring childhood (Items 3, 5, and 1), ormore generally the mental health of those inloco parentis (Items 9 and 33). Somewhatless central is a belief that abnormal behav-ior is motivated; e.g., mental illness is anavoidance of problems (Item 4), successfulpeople seldom become mentally ill (Item 67) .Accordingly, Factor E has been named Inter-personal Etiology. It accounts for 10% of theshared variance in each hospital.

Factor Scores

To obtain measures of each factor, itemswhich loaded each factor most highly andwhich had mental illness content were com-posited by assigning integral values from oneto six to the six alternatives from stronglydisagree to strongly agree for the positivelyloaded items, and in reverse order for thenegatively loaded items. Item scores were notstandardized, since their standard deviationsdid not vary greatly, nor were weighted as a

function of their factor loadings, since it hasbeen demonstrated that this refinement haslittle advantage over the simpler unit weights(Trites & Sells, 1955). Each item used forfactor scoring was assigned to only one fac-tor, in order to keep the factor scores experi-mentally independent. Constants were added,as necessary, to avoid negative scores.

The psychometric characteristics of the fac-tor scores are given in Table 6. The reliabilitycoefficients given are of the internal consist-ency type, equivalent to those obtained bythe generalized Kucler-Richardson Formula 20(Tryon, 1957), and are to be understood asgiving an estimate of the correlation onewould obtain from composites of the samenumber of items drawn randomly from thesame item domain (Tryon, 1957). They aredeemed quite satisfactory for our researchpurposes, possibly excepting Factor D. How-ever, in the light of Factor D's higher factorvalidity coefficients, and significant demo-graphic correlates (see below), its reliabilityis apparently adequate.

The factor validity coefficients were com-puted by means of Thomson's (1951, pp. 197™199) pooling square. The resulting value rep-resents the correlation coefficient between thesum of a set of item scores and the factorthey share in common. The validity coeffi-cients are also quite satisfactory for the pur-poses of group comparisons.

Although the abstract factors defined bythe quartimax rotation are mutually inde-pendent, the factor scores show some smallcorrelations (Table 6). In both hospitals one

356 JACOB COIIKN AND li. L. STKUJUNING

TABLE 6K K I . I A I H I . I T I K S , FACTOR VALIDITIES, AND TNTERCORRKLATIONS

OF THE OMI FACTOR SCORES IN HOSPITALS I AND IT

Scale

A[jCD1C

13111197

Reliability

I

8249602160

II

7662612359

Validity

I

8967564378

II

7376656766

Intel correlations'1

A

-20-26

2008

B

-19

28-12

14

C

-3911

-3024

D

22

K

16-15 , 03-28

05

25-02

11

Note.-— Decimal points omitted.il Number of items.b Hospital I iibovc diagonal; Hospital II below.

finds a weak link between Authoritarianism(Factor A) and Social Restrictiveness (Kac-lor D), another between Benevolence (FactorB) and Mental Hygiene Ideology (FactorC), and negative correlations across these twopairs. Interpersonal Etiology (Factor E) hassmall correlations with Mental Hygiene Ide-ology (Factor C), but, perhaps surprisingly,is uncorrelatccl with Authoritarianism (Fac-tor A) and Social Restrictiveness (Factor D).It must be stressed that these relationshipsare quite small; of the 20 correlations in thetwo hospitals, only one exceeds ,30.7 One mustbe prepared to find all patterns of high andlow scores on the five factors; no factor scorepredicts another to any material degree. Re-spondents low on Authoritarianism are nomore likely to accept Interpersonal Etiologythan those high on this factor. Respondentshigh on Mental Hygiene Ideology are onlyslightly more likely to reject Social Restric-tiveness than those low on this factor.

Demographic Correlates

To study the relationships between theOMI factors and occupation, education, age,and sex, each hospital sample was brokendown into subgroups for each demographicvariable and simple analyses of variance per-formed on each OMI factor score. In addi-tion to determining the significance of the de-parture from the overall null hypothesis, eachanalysis was extended to yield an eta coeffi-cient of nonlinear correlation to make pos-

7 A reviewer points oul that these correlations areattenuated by the measurement error variance in thefactor scores. This must be granted. Still, when theyare corrected for attenuation, they reflect less than?0% shared variance in all but two or three instances.

sible an assessment of the degree of associa-tion between the demographic variable andfactor score involved.8 Where applicable, theform of the regression of factor on demo-graphic variable was determined.

Occupation. Table 7 presents the mean fac-tor scores for 10 occupational groups whohave daily patient contacts. Physical Medi-cine and Rehabilitation and Special Servicesare charged with carrying on "activity" ther-apies with patients. The mental health pro-fessional groups include residents and trainees.The Physicians groups are made up predomi-nantly of nonpsychiatric physicians, but in-clude dentists and chaplains. The occupa-tional groups are significantly (p < .01) dif-ferentiated on all factors in both hospitals,excepting only Social Reslrictiveness in Hos-pital II. As can be seen from Table 7, thesubgroup differences are particularly markedon Authoritarianism (Factor A), where theeta values .65 and .SO indicate (through theirsquares) that 42% and 25% of the scorevariance is associated with occupation sub-group membership. The correlations with oc-cupation are also substantial for Benevolence(Factor B) and Mental Hygiene Ideology(Factor C), but noticeably smaller for theremaining two factor scores.

The sheer volume of data in Table 7 pre-cludes detailed discussion, but certain high-lights may be noted:

1. On Authoritarianism (Factor A), asmight be expected, psychologists, psychia-trists, and social workers have low means,while those of aides and kitchen personnel

8 In the case of sex, the analogous t ratios andpoint biscrial correlation coefficients were found.

OPINIONS ABOUT MENTAL TLLNKSS 357

TABLE 7MEANS AND ANALYSIS OF VARIANCE RESULTS OF OMI FACTOR SCORES

BY OCCUPATIONAL GROUPS IN HOSPITALS I AND II

o

Clericalhysical Medicine andRehabilitation

Jursestidessychiatristsocial Workershysicianssychologistspecial Serviceskitchen WorkersTotal Sample)

;••»Peta

1927

35254

131311361894

(541)

3325

53317

56

101914

120(653)

Factor A

I

18.819.6

16.528.413.413.419.511.914.931.1

(24.8)41.1

.01

.65

II

19.323.8

21.227.814.816.522.215.017.531.3

(26.4)22.0

.01

.50

Factor B

I

44.344.3

45.543.743.840.942.537.445.842.0

(43.1)7.9.01.35

II

46.344.1

45.143.840.841.043.238.844.641.8

(43.5)5.7.01.28

Factor C

I

34.135.8

36.533.038.737.934.143.636.933.0

(34.6)14.3

.01

.45

II

36.438.5

34.132.535.641.537.640.137.132.9

(33.6)9.1.01.35

Factor D

I

20.320.7

20.519.120.819.223.416.519.619.9

(19.4)3.5.01.24

II

19.318.7

20.820.318.819.723.518.219.019.6

(20.0)1.8ns.16

Factor E

I

19.319.7

20.118.621.216.920.421.616.920.0

(19.2)2.6.01.21

II

21.719.3

19.619.124.221.021.423.119.218.2

(19.2)3.7.01.23

» For Hospital I df = 9/510; for Hospital II df = 9/592.

are high. Gilbert and Levinson (1956) foundexactly parallel occupational differences onthe CMI, which again attests to the simi-larity between their scale and Factor A.

2. Psychologists again occupy the low ex-treme on Benevolence (Factor B), while thehigh end is taken by Special Service person-nel, nurses, and ward clerical personnel. Thislatter finding does not imply that psycholo-gists are malevolent—it is rather the moral-istic-paternalistic perspective of Factor Bwhich they reject.

3. Aides and kitchen workers have thelowest means on Mental Hygiene Ideology(Factor C), and psychologists, social work-ers, and Hospital I psychiatrists have thehighest means, a state of affairs inversely

paralleling that of Authoritarianism (FactorA).

4. While Social Restrictiveness (Factor D)does not spread the groups apart strongly, itis striking to find in each hospital that thephysician subgroup is by far the highest,while psychologists are the lowest.

5. Finally, and quite predictably, psycholo-gists and psychiatrists most strongly acceptInterpersonal Etiology while aides and kitchenworkers tend to be low.

Differences in orientation towards the men-tally ill among the various occupationalgroups are striking. Typically, the mentalhealth professionals are at opposite polesfrom the aides, who provide the quantitativebulk of the "normal" social atmosphere for

TABLE 8MEANS AND ANALYSIS or VARIANCE RESULTS OF OMT FACTOR SCORES

iiY YEARS OF EDUCATION IN HOSPITALS I AND II

Years ofeducation

- 89-11

1213-1516-1819-

7?n

Peta

' For Hospital I df = 5/511; for Hospital II df = 5/628.

46129144607958

120161177866227

Factor A

I

31.729.827.922.415.813.171.8

.01

.64

II

31.529.825.524.219.015.344.5

.01

.51

Fac

I

42.442.744.045.843.240.6

6.7.01.25

Factor C

I

33.233.233.033.936.840.919.2

.01

.40

II

31.832.933.333.737.838.613.1

.01

.31

Factor D

I

19.419.219.419.720.718.22.0ns.14

II

19.619.920.320.419.819.00.8ns.08

Factor 1C

I

20.218.719.418.718.821.12.4

.05

.15

II

18.418.818.920.120.623.36.5.01.22

358 JACOB COHEN AND E. L. STRUENING

patients, the nurses falling in between (butnote that Factors B and D depart from thispattern). The existence of such diversity ofview attests to a host of problems in com-munication in the occupational hierarchy andconsequently in patient care.

Education. This variable is related to oc-cupation and parallels it for the OMI factors(see Table 8). Again the two hospitals arevery similar. Since years of education is anordered variable, it is possible to consider theshape of the regression of factor score oneducation, as well as the significance and de-gree of relationship.

1. Authoritarianism (Factor A) shows asharp negative linear relationship with edu-cation of the order of .6 and .5 for the twohospitals, quite similar to the degree of rela-tionship provided by the highly correlatedoccupation grouping. This is quite in keepingwith the repeated findings of negative corre-lation of education and F Scale score, which,as already noted above, is considered to beessentially the same factor as A.

2. Benevolence (Factor B) has a weakerbut significant inverted U shaped relation-ship with education in both hospitals, thepeak coming in the "some college" (13-15)group. It drops off at higher levels, againpresumably because of increased rejection ofthe moralistic basis for the benevolence ratherthan the benevolence itself. The low level ofFactor B at elementary and high school lev-els is puzzling. Perhaps the Authoritarianismat these educational levels precludes Benevo-lence, just as Mental Hygiene Ideology athigh educational levels precludes it.

3. Education is somewhat more stronglyrelated to Mental Hygiene Ideology (FactorC), accounting for about 10-15°/o of its vari-ance. The regression is such that the meansremain constant from elementary throughsome college education and then rise sharplywith graduation and postgraduate training.This finding in conjunction with the relatedfinding on occupation supports the interpreta-tion of Factor C as the mental health profes-sional's creed.

4. Social Restrictiveness (Factor D) failsto relate significantly to education and wasslightly (Hospital I) and nonsignificantly(Hospital II) related to occupation. Althoughthis is psychometrically the weakest of the

factor scores, it nevertheless has enough fac-tor validity to disclose an important relation-ship where it exists, given the large samplesstudied here (see age and sex below). Theconclusion that Factor D does not relate toeducation, therefore, seems justified and fur-ther helps distinguish it from Authoritarian-ism, which is strongly related to education(and occupation).

5. Although significant, the relationship be-tween years of education and InterpersonalEtiology (Factor E) is weak. Insofar as itcan be discerned, in Hospital II the regres-sion is positive with a sharp rise at the post-graduate level; in Hospital I the latter risealso appears, but it zigzags anomalously atlower levels.

Age. The OMI factor scores do not relateas strongly to age as they do to occupationand education.9 Neither Benevolence (FactorB), nor Mental Hygiene Ideology (FactorC), nor Interpersonal Etiology (Factor E)are significantly related to age in either hos-pital, and the remaining factors are notstrongly related.

1. Age accounts for about 5% of the vari-ance on Authoritarianism in both hospitals,but does so in an unanticipated U shaped re-gression whose trough comes in the thirties.The conservatism of middle age is an oftenobserved phenomenon, but no reason comesto mind for the Authoritarianism (as high orhigher) of the teens and twenties. This maymerely be a peculiarity of the age-education-occupation structure of these two mental hos-pitals which deserves no general inferences.In any case, the relationship is a weak one.

2. The relationship of age to Social Re-strictiveness is even weaker and takes theform of a slow increase in score with age.

Sex. Like age, sex is only weakly related tothe factor scores.0 The sex differences on Au-thoritarianism (Factor A), Mental HygieneIdeology (Factor C), and Interpersonal Eti-ology (Factor E) are not significant. The

9 Tables giving these detailed findings have beendeposited with the American Documentation Insti-tute. Order Document No. 70S7 from ADI AuxiliaryPublications Project, Photoduplication Service, Li-brary of Congress; Washington 25, D. C., remittingin advance $1.25 for microfilm or $1.25 for photo-copies. Make checks payable to: Chief, Photodupli-cation Service, Library of Congress.

These tables are also available from the authors.

OPINIONS ABOUT MENTAL ILLNESS 359

others are significant in both hospitals, butof little consequence, in no instance account-ing for as much as 3% of the variance.

1. Women show somewhat higher Benevo-lence (Factor B) scores on the average thanmen, a fact that accords with their culturalrole. (It should be recalled, however, thatnurses were the highest occupation subgroupon this factor and account for a quarter to athird of the sample of women.)

2. Women also show somewhat higher So-cial Restrictiveness (Factor D) than men,but this may be an artifact. Several of theitems on this scale either explicitly (Items 40and 48) or implicitly (Item 52) are couchedin terms of what women should do in maritalrelationships with male mental patients. Werethe shoe on the other foot, this differencemight disappear or be reversed.

DISCUSSION

The Gilbert-Levinson (19S6) CMI can beinterpreted in the light of the results of thefactor analysis. Their initial conception ofcustodialism-humanism has our Factors Aand D at the custodialism pole, C and by im-plication E at the humanism pole, and B scat-tered all along it. The tendency for Authori-tarianism (Factor A) to dominate collectionsof items such as they and we used taken withtheir Likert method of procedure resulted intheir final CMI scale being largely a measureof Factor A. This leaves the other dimensionswe have uncovered unaccounted for in theirscheme.

The importance of this omission cannot, atpresent, be fully assessed, since the role ofthe other dimensions with regard to the effi-cacy of patient care has not yet been studied.We speculate, however, that more than Au-thoritarianism is important in regard to hos-pital, family, and community atmosphere andits relation to the well-being of mental pa-tients. For example, we think that Benevo-lence (Factor B) is an important quality inpsychiatric aides and nurses, who provide thebulk of the patients' contact with "normals,"and represent the hospital to them. We be-lieve that present educational programs forpsychiatric aides seek to inculcate in themthe ideology of the mental hygiene move-ment (Factor C), which is at least foreign,

quite possibly anxiety provoking, and in anycase not very effective. This probably ac-counts for the failure of the Cummings'(1957) community education effort; the con-ception "Mental patients are different fromyou only in degree," a Factor C idea, provedflatly unacceptable to the community. Per-haps the message, "Mental patients are poorunfortunates whom we should help out ofsimple human kindness," a Factor B formu-lation, might have proven more effective, de-spite its condescending sound in the ears ofprofessionals.

Such speculation as the above, althoughinteresting and perhaps even exciting, is notmeant to replace the empirical work thatneeds to be done, but merely to provide abasis for generating hypotheses for such work.

The substantial differences in factor scoresfound as one goes up the occupational-educa-tional hierarchy of the two mental hospitalsstudied, particularly in the light of the con-sistency found between these widely sepa-rated hospitals, merits thoughtful attention.At least some of the friction found betweenprofessional groups in hospitals and some ofthe failures in communication between thosewho give orders and those who carry themout is in manifestation of widely separateviews of the nature and progress of mentalillness held by different occupational groups.The diagnosis of this problem (as in psychi-atry generally) leads to no immediate sure-fire treatment. Whether educational effortswithin the hospital and community can beeffective is problematic. If, for example,Authoritarianism is characterologically im-bedded, as the California group suggests(Adorno et al., 1950), no lecture series willdispel it. Perhaps, in hospitals at least, per-sonnel selection on attitude factor scores mayprove salutary for patients. But this shouldbe preceded by empirical evidence concern-ing the relationships we all assume.

The present report describes the first stepin a larger investigation. Work in progress in-cludes assessment of opinion in the largercommunity, in the families of mentally ill vet-erans, and the relationship between person-nel OMI factor scores and patient releaserates over the 12 mental hospitals of the Vet-erans Administration's Psychiatric EvaluationProject.

360 JACOB COHEN AND E. L. STEUENING

SUMMARY

A collection of 70 Likert-type opinion items,largely relevant to the mentally ill, was ad-ministered to most of the employees havingfrequent contacts with patients in two large,geographically widely separated Veterans Ad-ministration neuropsychiatric hospitals (N= 541 and 653). The purpose of this in-vestigation was to identify and measure thesalient dimensions underlying these opinionsand to begin the exploration of the constructvalidity of these dimensions by determiningtheir relationships to the respondents' occu-pation, education, age, and sex. To this end,in each hospital separately, the item inter-correlations were subjected to centroid fac-tor analysis followed by quartimax rotation.Scales were developed to measure each of thefive factors identified in the analyses, and theresulting factor scores were related by analy-ses of variance to occupation, education, age,and sex. The results of all analyses in thetwo hospitals were the same in all essentialregards; thus, the following conclusions applyto both:

1. Five salient opinion-attitude dimensionswere identified. Therefore, attempts to workin this area with single scales (e.g., "pro-anti"mental patient, custodialism-humanism) over-simplify this domain. Further, correlationsamong factor scores for these dimensions aretrivial or zero. The five factors were:

Factor A—Authoritarianism. This is clearlyidentified with the California F Scale and in-cludes its authoritarian submission and anti-intraception combined with a view of thementally ill as an inferior class requiring co-ercive handling. It accounts for about halfthe communal variance among the items, theother factors sharing the remaining half aboutequally.

Factor B—Benevolence. A kindly, pater-nalistic view towards patients whose originslie in religion and humanism rather thanscience.

Factor C—Mental Hygiene Ideology. Apositive orientation which embodies the tenetsof modern mental health professionals and themental hygiene movement whose leitmotif is"mental illness is an illness like any other."

Factor D—Social Restrictiveness. The cen-tral belief here is that the mentally ill are athreat to society, particularly the family, and

must therefore be restricted in their function-ing both during and after hospitalization.

Factor E—Interpersonal Etiology. A cir-cumscribed factor whose positive pole reflectsthe belief that mental illness arises from in-terpersonal experience especially deprivationof parental love during childhood.

2. Among the demographic variables, occu-pation and the closely related variable of edu-cation are substantially related to factorscores, particularly Factors A, B, and C. Edu-cation gives rise to curvilinear relationshipswith Factors B and C.

3. Age and sex show either zero or weakrelationships with the factor scores.

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THOMSON, G. The factorial analysis of human abil-ity. (5th ed.) New York: Houghton Mifflin, 1951.

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(Received March IS, 1961)