Changing attitudes towards the mentally handicapped:

THE IMPACT OF COMMUNITY CARE 3

DAVID LOCKE;, BRIDGET RAO: JEAN M. WEDDELL

Department of Community Medicine, St.

Introduction In 1977 adults living in the six streets surrounding

the proposed site of a hostel for the mentally handi- capped were interviewed. The aim of the survey was to investigate the extent and origins of opposition to the hostel. Data was collected on the respondents’ knowledge of and attitudes towards mental handicap. The relationship between this data and opinions about the hostel were investigated. The results of this sudy have been reported in a previous paper (Locker, Rao and Weddell, 1979). In 1980 a second survey was conducted, of adults living within the same geographi- cally defined community. The aim was to determine the extent to which public responses to the hostel and the mentally handicapped change following the provision of community care.

Method In 1977 a random start, systematic one-in-four

sample was drawn from the electoral register covering the six streets to be surveyed. This produced a list of 271 named individuals, 196 of whom were interviewed. In 1980, a comparable sample was drawn from the 1980 electoral register covering the same community. This produced a list of 245 named individuals. Since 24 of these had been interviewed in 1977 they were excluded from the study and replaced with the persons next listed on the register. This produced a second sample, broadly representative of the community, who had not been interviewed previously about mental handi- cap and community care. This was to ensure that any changes observed were not due to the effect of previous questioning.

The first questionnaire was administered to the 1977 sample three months before the hostel was due to open. It was designed to collect information on the respondents’ opinions about the hostel and its impact on the community, their knowledge of mental handicap and community care, and their attitudes towards the mentally handicapped. The second questionnaire was administered to the 1980 sample two years after the hostel became fully operational. Most questions were identical to those in the first questionnaire but there were additional questions concerning contact with the hostel, its residents and staff.

The hostel in question is supported by a voluntary organisation and has been specially converted from two semi-detached houses to provide a long-term home in the community for 14 people, nine of whom are mentally handicapped men and women.

1 . Currently, Department of Sociology, University of Surrey, Guildford, Surrey.

2. Currently, Department of Adult Psychiatry, St. George’s Hospital Medical School, London, S.W.16.

3. Currently, Allied Medical Group, 18 Grosvenor Gardens, London S.W.l.

92 Apex.

Thomas’s Hospital Medical School, London

Response In 1977, 36 of those sampled had moved or died.

If these are excluded the completed interviews repre- sent a response rate of 83 per cent. Of those sampled in 1980, 35 had moved or died and 176 of the re- mainder were interviewed. If those no longer resident in the community are excluded this produces a res- ponse rate of 84 per cent.

Results OPINIONS ABOUT THE HOSTEL

Data concerning people’s opinion of the hostel was collected by means of an open-ended question. The responses were sorted into five categories. As Table 1 shows there is a significant difference between the 1977 and 1980 surveys in the distribution of responses across these categories. 20 per cent of the former were opposed to the hostel compared to only two per cent of the latter. There were also significant differences in opinions about the impact of the hostel on the com- munity. 26 per cent of those interviewed in 1977 felt the hostel would have disadvantages for the com- munity compared with six per cent in 1980 (p ( .001).

KNOWLEDGE OF MENTAL HANDICAP In order to determine respondents’ knowledge of

mental handicap they were asked: “If I said someone was mentally handicapped what would you think that meant?” Using the criteria of intellectual impairment and social incompetence the responses were cate- gorised as Clear, Partially confused, Confused or Don’t know (see Locker, el al 1979 for details of the classification procedure).

Table 2 shows that there were no significant differences between the 1977 and 1980 surveys in the distribution of responses across these categories. How- ever, there were significant differences in the responses to a subsidiary question about mental handicap’s prognosis. As Table 3 shows, in 1977 41 per cent of the respondents were correct in stating that mental handi- cap was not a condition that could be cured, compared to 56 per cent in 1980 (p ( .025).

KNOWLEDGE OF COMMUNITY CARE There were also significant differences between the

1977 and 1980 surveys in the proportion of people interviewed who had heard of the term “community care.” Two-fifths and one-half respectively responded positively to this question (p ( .025). However, the pro- portion able to give an adequate definition of com- munity care only increased from 28 to 32 per cent.

ATTITUDES TOWARDS THE MENTALLY HANDICAPPED AND COMMUNITY CARE

Tables 4, 5 and 6 give the responses to attitude statements concerning mentally handicapped people and community care. There was a significant

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difference in the percentage of respondents who agreed with one of the six statements relating to the characteristics of the mentally handicapped, that is, fewer people in 1980 equated mental handicap with psychiatric disturbance (p ( .05) (Table 4). There were, however, significant differences in the responses to three out of the four statements concerning social distance (Table 5) . More of the 1980 sample said they would not mind working with a mentally handicapped person (p ( .025) or having a mentally handicapped person living next door (p ( .025), and more were willing to have a mentally handicapped person visit their home (p ( .01). Responses to the statements about care of the mentally handicapped (Table 6 ) reveal a shift in preference away from hospitals to the comunity. Only two-fifths of those interviewed in 1980 thought that the mentally handicapped were well cared for in hospital, compared with over half of those interviewed in 1977 (p ( .01). Significantly more agreed that it is good for the mentally handi- capped to live in the comunity (p ( .001) and that they benefit from contact with ordinary people (p ( .001). There were no differences in the proportion who agreed that everyone has a responsibility to help the mentally handicapped, or the proportion who thought hostels provide the ideal form of care.

CONTACT BETWEEN THE RESPONDENTS, THE HOSTEL AND ITS RESIDENTS

Table 7 summarises the answers of the 1980 sample to questions designed to give an indication of the con- tact between the local population, the hostel, and the mentally handicapped. In all cases less than 10 per cent responded positively. For example, only 6 per cent had visikd the hostel and 2 per cent had been visited at home by a mentally handicapped resident. Although direct contact appears to be minimal, many of the people interviewed mentioned spontaneously that they had seen the residents around the com- munity, in local shops or using public transport.

TABLE 1. Respondent opinion of the hostel -

1977 1980 (70 onlv) n = 188. n = 176

Enthusiastic 30.1 28.4 No objections 31.0 63.6 Opposed 20.8 2.3 Indifferent 12.8 1.7 Not categorised 5.3 4.0

Total 100.0 100.0

*Excludes cases where opinion not recorded X2 test p ( .001

TABLE 2. Understanding of the term “mental handicap” 1977 1980

(70 only) n = 196 n = 176 Clear Partially confused Confused Don’t know

53.1 10.7 18.4 17.8

56.8 11.4 13.6 18.2

Total 100.0 100.0

X2 test: NS

TABLE 3. Prognosis of mental handicap 1977 1980

I% onlvb n = 196 n = 176 Curable 25.0 20.0 Incurable 41.3 56.0 Don’t know 33.7 24.0

Total 100.0 100.0

TABLE 4. Responses to statements concerning the characteristics of the mentally handicapped

1977 1980 (YO agreeing) n = 196 n = 176

1. Someone who is mentally handicapped is more likely to steal than anyone else 4.6 7.3 NS

2. The mentally handicapped are no more likely to behave strangely than most other people 41.5 44.5 NS

3. Mentally handicapped people are dangerous 7.1 4.5 NS

4. It is not safe to let children have any contact with the mentally handicapped 16.6 12.9 NS

capable of leading useful lives 78.4 82.4 NS

are psychiatrically disturbed 28.1 18.1 p ( .05

5 . Mentally handicapped people are

6. Most mentally handicapped people

TABLE 5. Responses to statements about social distance

(Yo agreeing) n = 196 n = 176 1977 1980

1. I would not mind a mentally handicapped person using the same shops as me 94.4 97.7 NS

2. I would not mind working with someone who is mentally handicapped 71.4 82.5 p ( .025

3. I would not mind having a mentally handicapped person living next door 72.9 84.2 pc .025

4. I would be willing to have a mentally handicapped person as a visitor in my home 49.2 64.2 pc .01

TABLE 6. Responses to statements about community care

tolo aereeine) n = 196 n = 176 1977 1980

1. It is good for the mentally handicapped to be living in the community 83.8 93.2 p (.01

2. Mentally handicapped people benefit from the experience of living with ordinary people 80.0 95.9 p ( .001

3. Mentally handicapped are well cared for in hospital 55.9 41.2 p ( .01

4. It is everyone’s responsibility to help the mentally handicapped to live a normal life 88.3 87.6 NS

5. Living in a hostel gives the mentally handicapped chance to live the same life as anyone else 76.1 82.9 NS

TABLE 7. Contact between the respondents, the hostel, and its residents*

Per cent who have visited the hostel 6 Per cent who know one or more members of staff 4 Per cent who know one or more mentally handicapped resident(s) 6 Per cent visited at home by a member of staff 2 Per cent visited at home by a mentally handicapped resident 2

“1980 sample only. N = 176

Conclusion The results of this follow-up survey show that

people living near the hostel are more favourably in- clined than they were in 1977. Possibly because the experience of living close to the hostel has shown that the negative consequences anticipated in 1977 have not been realised, the proportion of interviewees having no objections to the presence of the hostel rose from 60 to over 90 per cent. In 1977 many respondents thought that in the community the mentally handi- capped would create anxiety among the local popula- tion, pose a danger to children and the elderly, increase violence, and be a menace on the roads. Few expressed

Continued on page 95 X2 test, p ( .025

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1974 and 1980, 199 patients were admitted. Of those, 144 were returned to the community and a further 36 to NHS hospitals. Over half the patients were diagnosed as having psychopathic disorder, confirming the previous speaker’s belief that units in mental handicap hospitals can deal effectively with clients whose intelligence is not unduly low.

Aggression is, of course, a behaviour which causes concern in hospitals and other institutions as well as in the general community. Mr. K. Faulkner, Senior Tutor at Moss Side Hospital, outlined the various theories of aggression (including biological, psycho- analytical, and social learning). He went on to describe means of seeking to control violence, particularly by the establishment of a stable hierarchy. He suggested that patients in hospital security units may be under too close observation to allow this. For staff working with violent and aggressive patients, appropriate train- ing and support is essential.

Mr. Faulkner then went on to describe means of anticipating and dealing with actual incidents of aggressive behaviour, highlighting the need to use the least violent - preferably non-violent - means of containing aggression, to avoid inconsistent attitudes to violence, and to develop social programmes designed to emphasise non-violent alternatives in conflict resolution.

All three speakers above stressed the need for full multidisciplinary input, and for appropriate support and conditions of service.

Mr. S. C. O’Kane, National Officer of the Con- federation of Health Service Employees, developed this theme and reminded the audience of the main recommendations of COHSE’s well received document “The Managvent of Violent or Potentially Violent Patients”. He rejected the idea that mental handicap hospital staff are responsible for the number of people misplaced in special hospitals and prisons, pointing out that his Union had been in the forefront of advocating proper secure provisions and satisfactory staffing levels, not just to protect the staff but to ensure that the clients had high quality care.

Whilst the conference was set up to explore essentially practical ways of dealing with this group of clients. there was some discussion on the concept and implica- tions of “dangerousness”. Dr. Canning pointed out the common use of the term in two forms: firstly, the risk of a new economic crime, usually of the same type previously committed; and, secondly, severe aggressive or sexual activity. The latter is generally regarded as a more serious crime, too little attention being paid to the victim of the former crime. Dr. Canning expressed thc view that the selection of any client for admission to a unit such as the one at Coleshill Hall must include a judgement as to whether the patient would be likely to commit a dangerous offence within a few hours of escape.

To conclude All in all the conference appears to have indicated

that developments such as the units described, together with provision of properly trained care staff, and sup- portive staff with correct attitudes, can lead to successful management of this difficult group of clients outside of special hospitals. Inevitably, the problem of the aggressive or otherwise difficult severely or profoundly retarded person could only be touched upon in the time available and this is clearly a topic for much further study and discussion.

The conference was reasonably well-attended, the audience being mostly nurses, with a sprinkling of doctors and psychologists and, interestingly, some DHSS observers. From the discharge figures a t the Eastdale Unit one would have thought that local social services departments might have been more interested.

References Butler Committee. Report o f the Committee on Abnormal

Offenders. Cmnd. 6244. London : HMSO, 1975. The Management o f Violent or Potentially Violent Patients.

London : Confederation of Health Service Employees, 1971. Copies of the papers by Mr. Faulkner and Mr. O’Kane are available from the British Institute of Mental Handicap. Information on Dr. Canning’s and Dr. Hunter’s contributions can be obtained direct from them.

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these, or other, fears in 1980. It would appear that the campaign by some local residents to create opposition to the hostel did not have a lasting effect.

The 1980 survey also reveals that, while the respon- dents’ knowledge of mental handicap has not changed, attitudes towards mentally handicapped people and community care have become significantly more positive. The local residents are now more prepared to have closer contact with the mentally handicapped. are more favourably disposed to community care, and recognise the benefits of locally-based residential units. In 1977 many respondents assumed that an ideal form of care involved isolation, open space, and a quiet, peaceful atmosphere - ideas reinforced by the pro- vision of custodial care in institutions remote from centres of population. Consequently, some were opposed to the hostel because they felt it inappropriate to the needs of the mentally handicapped. The change in orientation shows a growing awareness that com- munity care exists as a viable alternative to care in institutions. However, it would appear that more could be done to better inform the public of its precise aims and objectives.

The observation that respondents’ knowledge of the term “mental handicap” had not changed between the surveys deserves further comment. While the distri- bution of responses across the categories employed

remained the same, there were some important differences in the content of the replies. In 1980 more respondents mentioned that there were different degrees of mental handicap, more gave mongolism as a specific diagnosis, and more drew a distinction be- tween mental handicap and mental illness. In addition, other data show that significantly more understood that mental handicap could not be cured and signifi- cantly fewer believed the mentally handicapped to be psychiatrically disturbed. It is not unreasonable to conclude that these results indicate the beginnings of an increase in understanding on the part of the local population.

On the basis of the data in the survey described here, it would appear that the provision of community care provides the general public with experience of mental handicap and serves to increase awareness and tolerance. Although direct contact is limited, the extent of the difference in responses to the 1977 and 1980 questionnaires suggests that the mere presence of mentally handicapped people in the community has a positive educational effect.

Although relatively few of the people interviewed had visited the hostel or met the residents many expressed a willingness to do so. Though the hostel operates with an open door policy and encourages

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MENrALLv ILL HEN ----- - WCNTALLY HANDICAPPED MLN

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“ 1 / HONTUS S I N C E DISCHARGE 1

I I I

4 I I2 16 2 0 a, 2s

FIGURE 2. Length of stay in hospital after order for Male mental illness and mental handicap patients

The pattern of discharge for mentally ill and mentally handicapped females differed considerably from the male pattern, the females generally being dischargcd much sooner. Discussion

Responsibility for the decline in the use of hospital orders for mentally handicapped people seems to rest with changes which have taken place in the admission policy of mental handicap hospitals during the years of operation of the Mental Health Act of 1959. During this period, there has been a marked reduction in the number of beds available in mental handicap hospitals which have tknded to concentrate their efforts upon looking after severely handicapped people and in pro- viding short-stay assessment and holiday/relief support for the families of mentally handicapped people living in the community.

So few orders are now made that it raises the question of whether there is still a need for courts to be enabled to make hospital orders for mentally handi- capped people at the level of the Section 60 order. The recommendations contained in the government White Paper of 1978, to which I referred earlier, do not support such a change in legislation. The White Paper states that, having considered the many arguments raised in opposition to the continued grouping together of mental illness and mental handicap, “. . . it is also recognised that mentally handicapped people were more usually detained in hospital under compulsory powers

not because of intellectual retardation or diminished social competence as such but because their behaviour appeared to present a threat either to themselves or to others. Similarly, it is the behaviour of some mentally ill people which warrants their detention rather than the mental illness itself”. (1.18)

This is a reasonable argument to adopt in regard to the Part IV (civil) section of the Act and to the use of restriction orders under Section 60/65, but it is a much less reasonable argument when considering unrestricted Section 60 orders. The intervention of the courts, through the use of hospital orders, has made mentally handicapped offenders unnecessarily vulnerable to in- appropriate hospitalisation. Witness, for example. the discharge pattern of the sample under discussion and the fact that only 50 per cent of them had ever needed to be hospital in-patients before their court appearance. Under the present Act, courts are not encouraged to distinguish between handicap and illness, yet the nature of the relationship between disorder and offending behaviour is fundamentally different in the ill and handicapped groups. Very often, the ill offender may be acutely disturbed and in need of hospital care, whereas the young mentally handicapped man who steals, though different in some respects from other offenders, cannot be said to have acted differently “from himself” any more than any other offender. The occasion of a court appearance is unlikely to be the best time to make decisions regarding admission to a hospital.

The White Paper of 1978 suggests new powers to make people subject to supervision in the community, and it would seem to me that such powers would do away with the need for a Section 60 type of unrestricted order for mentally handicapped people. The same does not hold true for the type of offence and offender at present dealt with by the use of hospital orders under restriction, but this issue is outside the scope of the present paper. Acknowledgements

I am indebted to Professor T. C. N. Gibbens and to Mrs. Sarah McCabe. Although the research was carried out whilst in receipt of a grant from the Home Office the views expressed are my own. References Craft, M. J. The moral responsibility for Welsh psychopaths.

In The Mentally Abnormal Offender. London: J. and A. Churchill, 1968. (OOP.)

Review of the Mental Health Act, 1959. Cmnd. 7320. London: HMSO, 1969.

Walker, N., McCabe, S., Crime and Insanity in England: Vol. T w o : New Solutions and New Problems. Edinburgh : Edin- burgh University Press, 1973.

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local people to visit, the respondents seemed unaware of this or of their own role in contributing to the well-being of the mentally handicapped. Constant effort is required by those responsible for the hostel to transform these more favourable attitudes into action.

Community care, meaning care by as well as care in the community, requires that the public is positively disposed towards the mentally handicapped. Where the right attitudes do not exist local opposition may prevent hostels from opening, or may limit the extent to which hostel residents become fully integrated into the community. The results of our initial survey sug- gested that local opposition could be reduced by the provision of information concerning the nature of mental handicap and the objectives of community care. The results of the follow-up survey indicate that living in proximity to the mentally handicapped helps

to create the attitudes necessary for integration but that further effort is required to make that integration a reality. Acknowledgements

We would like to thank Alice Smith, for sampling and statistical advice; Lesley Saltmarsh, Jenny Ash- bourne, Roger Swann and Michael O’Connell, who conducted the fieldwork and helped with the coding; and Professor W. W. Holland, Robert Maxwell and members of the Department of Community Medicine, St. Thomas’s Hospital Medical School, for support and advice. The study was financed by the St. Thomas’ Hospital Trustees. References Locker, D., Rao, B.. Weddell, J. M. Knowledge of and

attitudes towards mental handicap : their implications for community care. Community Medicine, 1979; 1 : 127.

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