Journd of Communiiy P.yehdow, 1078, 7. 336-342.

ROLE PERCEPTIONS IN A COMMUNITY MENTAL HEALTH SETTING*

HERBERT HARARI, KAREN HOSEY, A N D PATRICIA SHEEDY

San Diego Stale Universiiy

The increasing trend of utilizing nonprofessional personnel in community mental health has led to considerable controversy. It is suggested that studies comparing the relative competence and efficacy of professional therapists to that of nonprofessional therapists may be counterproductive and in need of augmentation. The present study employed a role perception procedure in which members of three different randomly chosen groups ( 1 I professional therapists, 1 I nonprofessional therapists, and I I children-clients) from a community mental health program were asked to rank various aspects of the therapeutic relationship in order of importance to the children- clients’ improvement. It was hypothesized that (a) due to their relatively low self- concept, nonprofessionals would underestimate their own role importance in com- parison to that of the professionals; (b) professionals would overestimate their own role importance; and (c) children would selectively value certain aspects of each role without preferring one over the other. The last two hypotheses were supported, but the first hypothesis was not: nonprofessionals, in fact, showed the highest level of overestimation of their own role importance. A further analysis of the data showed that inexperienced nonprofessionals did not overestimate their own role performance. This suggested specific training procedures for nonprofessionals.

The upsurge of community programs aimed at alleviating the shortage of professional mental health personnel in recent years has resulted in the emergence of a variety of nonprofessional services in diverse roles and settings (Cowen, Chinsky, & Rap- paport, 1970; Gruver, 1971). After surveying the success and practicality of over 10,OOO nonprofessionals in over 185 NIMH projects across the United States, Sobey (1970) suggested that there was a “nonprofessional revolution in mental health .” This revolu- tion has provided an important source of manpower, but has also produced certain con- comitant problems and considerable controversy concerning the use and efficacy of non- professionals.

Opinions concerning the use of nonprofessionals are conflicting (Genther, 1974; Goldenberg, 1973; Gruver, 1971; Keniston, 1967; Mitchell, 1966), and in view of their current widespread employment this controversy becomes a serious issue. Some researchers have attempted to determine whether untrained therapists can do an effective therapeutic job (Blau, 1969; Guerney, 1969; Sobey, 1970) and have even directly com- pared their effectiveness with that of professionals (Durlak, 1973). Meltzoff and Kor- nreich ( 1970) in an extensive review of comparative professional-nonprofessional therapeutic effectiveness studies cited numerous methodological shortcomings, such as inappropriate use of statistics, lack of control groups, sampling biases, lack of random assignment, and effectiveness criteria, to conclude that “a good controlled comparison of the effectiveness of trained and untrained therapists has yet to be made” (p. 288).

We doubt whether this worthy goal will ever be achieved. There are increasing restrictions on the use of human subjects for psychological research, especially in clinical settings. There are ethical questions to be considered when treatment is denied through the establishment of control groups, and there are practical considerations due to the

+Send reprint requests to first author, Department of Psychology, San Diego State University, San Diego, California 92182.

335

336 H E R B E R T H A R A R I , KAREN HOSEY, A N D PATRICIA SHEEDY

limited feasibility of subjecting patients to untrained laypersons. Perhaps the time has come to accept the emergence of nonprofessionals in the field of mental health as an ac- complished fact. Our own belief is that both professionals and nonprofessionals have the potential to offer their own unique benefits to patients.

Our basic thesis is that social-psychological research exploring the values, roles, and interpersonal perception of all therapists is a valuable augmentation to controversial, and somewhat futile, comparative studies of who is “best.” We base this belief on our ex- perience of involvement over a period of four years in a college companionship program where undergraduate (nonprofessional) students worked on a one-to-one basis with children in therapy while under the direct supervision of the childrens’ (professional) therapists.

In addition to such wide scope social-psychological exploration, we feel that research should be directed toward the establishment of clear roles for the non- professionals. Within the companionship program, we have frequently encountered feelings of frustration and expressions of self-derogation among the students toward their role as nonprofessional therapists (“unpaid babysitters”), and we believe that their self- esteem and satisfaction could be enhanced by a clearer definition of their unique con- tributions. Block (1974) maintained that paraprofessionals’ lack of identity results in lower morale because they are often unaware of their place in the overall mental health picture.

Accordingly, the present study involved a role perception procedure in which ran- domly selected members of the companionship therapy program (professionals, non- professionals, and children in therapy) were asked to rank various aspects of the therapeutic relationship in order of importance to the child’s improvement. It was hypothesized that (a) the nonprofessionals (students), due to their relatively low self- concept, would underestimate their own role importance in comparison to that of the professionals (therapists); (b) the professionals would overestimate their own role impor- tance; and (c) the children would selectively value certain aspects of each role and therefore, no clear-cut pattern could be predicted. In addition to examining these hypotheses, the study was designed to provide specific expectations and counterexpec- tations and thus to provide valuable information about this three-sided therapeutic relationship, and about the supervisory role of professional therapists.

METHOD Participants. Three groups of persons participated in this study. The first group con-

sisted of eight female and three male undergraduate psychology majors enrolled at San Diego State University. The second group consisted of six male and five female children who were outpatients at a San Diego Community Mental Health facility (median age 8.5, classified according to the general DSM category of Behavior Disorders of Childhood and Adolescence). The third group consisted of seven male and four female therapists (three psychiatrists, four psychologists, four social workers) at the same facility. All persons were randomly selected and were participating in the student com- panionship program.

Apparatus. Mitchell’s ( 1966) structured elements of nonprofessional therapy (amicatherapy) and professional therapy were employed as the basic dependent measure. From a social-psychological perspective, these elements can be viewed as various aspects of role position, role enactment, role expectations, status, and environment. The elements were written as statements on ten cards, with one set for the students and the

337 VALUES A N D ROLES

therapists, and one with identical statements, but in simplified language, for the children (The full listing is in Table 2).

Procedure. After being informed that the present experiment was designed to find which areas in companionship therapy the person felt were the most influential factors in the child's improvement, participants were requested to rank the ten elements (five for nonprofessional therapy and five for professional therapy) in order of importance (a rank of one to the most important factor, and a rank of ten to the least important factor). To control for varying levels of reading proficiency, the cards were read aloud to each of the children who were then asked to place the cards according to their perceived importance. Stacks of cards were rearranged in random order between each person's use.

RESULTS

TABLE 1 Comparaiive Rankings of Therapy by Professionals,

Nonprofessionals, and Children- Clients - Type of Therapy

Mean Rankings" by Professional Nonprofessional

Professionals 4.G9*

Nonprofessionals 7.00 Children-Clients 5.95

6.12

4.00. 5.05

"Higher mean scores are indicative of lower ranking. *p <.05.

Mean scores of the 10-point rankings for the respective elements of professional and nonprofessional forms of therapy served as the dependent variable. Means for the respec- tive groups are presented in Table 1. A factorial analysis of variance was employed as the preferred statistic in line with Winer's (197 1) procedure which showed that ordinal data will not differ significantly from score data in such cases. Accordingly, a 3 X 2 mixed analysis of variance was performed, with group membership (professionals, non- professionals, children in therapy) as the between factor, and type of therapy (non- professional, professional) as the within factor. This analysis resulted in a significant main effect for the type of therapy, F (1, 20) = 5.22, p < .05; and a significant type of therapy X group membership interaction, F (2, 20) = 9.53, p < .005. Subsequent com- parisons by means of the Newman-Keuls test showed that both professionals and non- professionals perceived their role as more important than the other's to the child's progress. No significant differences were found in the children's perception of the two therapy roles.

In addition to the above analysis, a 3 X 10 mixed analysis of variance of each group's rankings for the ten role elements of psychotherapy yielded a significant main effect for the items, F ( 9 , 270) = 31.25, p < .001 as well as a significant group X item in- teraction, F (18,270) = 28.41, p < .001. Mean scores were subsequently subjected to post-hoc comparison tests (higher mean scores are indicative of lower ranking). As can be seen from Table 2, Newman-Keuls specific comparison tests revealed that all groups ranked the fact that the nonprofessional saw the child at variable times in a supportive

TA

BL

E 2

Com

para

tive

Ran

king

s of

Rol

e E

lem

ents

in T

hera

py b

y Pr

ofes

sion

als,

Non

prof

essi

onal

s, an

d C

hild

ren-

Clie

nts

Typ

e of

M

ean

Ran

king

. by

St

atem

ent

The

rapy

St

atem

ents

to b

e R

anke

d Pr

ofes

sion

als

Non

prof

essi

onal

s C

hild

ren

All G

roup

s

Rol

e Po

sitio

n

1 Pr

ofes

sion

al

Adu

lt V

ersi

on:

The

fact

that

the

ther

apeu

tic a

gent

is a

pr

ofes

sion

al.

a do

ctor

or t

hera

pist

.

layp

erso

n.

The

fact

that

Bla

nk (

nam

e of

non-

pr

ofes

sion

al)

is ju

st a

noth

er p

erso

n lik

e a

big

brot

her

or b

ig s

iste

r.

Chi

ldre

n V

ersi

on:

Bec

ause

Bla

nk (

nam

e of

pro

fess

iona

l) is

2 N

onpr

ofes

sion

al

Adu

lt V

ersi

on:

The

fact

tha

t th

e th

erap

eutic

age

nt is

a

Chi

ldre

n V

ersi

on:

Rol

e E

nact

men

t

3 Pr

ofes

sion

al

Adu

lt V

ersi

on:

The

fact

tha

t the

pro

fess

iona

l se

es th

e ch

ild a

t spe

cifie

d tim

es, a

nd th

roug

h hi

s/he

r pr

ofes

sion

al o

rien

tatio

n tri

es

to p

rovi

de in

sigh

t. B

ecau

se I

see

Bla

nk (

nam

e of

pro

fes-

si

onal

) on

Bla

nk (

nam

e of

day

) so

he/s

he c

an h

elp

me

see

how

I re

ally

fe

el a

bout

stu

ff.

4 N

onpr

ofes

sion

al

Adu

lt V

ersi

on:

The

fact

tha

t the

non

prof

essi

onal

sees

child

at v

aria

ble

times

, and

thro

ugh

vario

us a

ctiv

ities

trie

s to

be

supp

ortiv

e an

d ed

ucat

ive.

with

Bla

nk (

nam

e of

non

prof

essi

onal

) at

diff

eren

t tim

es.

Chi

ldre

n V

ersi

on:

Chi

ldre

n V

ersi

on:

Bec

ause

of

lear

ning

and

doi

ng th

ings

2.33*

5.27

7.00

4.87

8.99

6.27

7.64

7.63*

5.22

4.89

4.55

2.55

5.55

4.89

3.82

3.76'

Role

Exp

ecta

tion

5 Pr

ofes

sion

al

Adu

lt V

ersi

on:

Chi

ldre

n V

ersi

on :

6 N

onpr

ofes

sion

al

Adu

lt V

ersi

on:

Chi

ldre

n V

ersi

on :

Stat

us H

iera

rchy

7

Prof

essi

onal

A

dult

Ver

sion

:

Chi

ldre

n V

ersi

on:

8 N

onpr

ofes

sion

al

Adu

lt V

ersi

on:

Chi

ldre

n V

ersi

on:

Envi

ronm

ent

9 Pr

ofes

sion

al

Adu

lt V

ersi

on:

Chi

ldre

n V

ersi

on:

10

Non

prof

essi

onal

A

dult

Ver

sion

:

Chi

ldre

n V

ersi

on:

The

fact

tha

t rem

issi

on o

f sy

mpt

oms

is

3.00

ex

pect

ed t

hrou

gh p

rofe

ssio

nal

effo

rt.

Bec

ause

I ha

ve B

lank

(na

me

of p

rofe

s-

sion

al)

who

can

hel

p m

e to

get

bet

ter.

The

fact

tha

t a fr

iend

-frie

nd r

elat

ions

hip

is ex

pect

ed b

etw

een

the

child

and

the

nonp

rofe

ssio

nal.

Bec

ause

I ha

ve B

lank

(na

me

of n

onpr

o-

fess

iona

l) th

at I

can b

e a

frie

nd w

ith.

5.78

The

fact

tha

t the

pro

fess

iona

l an

d th

e ch

ild r

elat

e on a

hie

rarc

hica

l ba

sis.

Bec

ause

Bla

nk (

nam

e of

pro

fess

iona

l) te

lls m

e w

hat t

o do

and

wha

t is

best

fo

r me.

T

he fa

ct th

at th

e no

npro

fess

iona

l and

th

e ch

ild a

re on

a m

ore

equa

l soc

ial

basi

s. B

ecau

se B

lank

(na

me

of n

onpr

ofes

sion

al)

is li

ke a

frie

nd w

ith w

hom

I c

an h

ave

fun.

7.67

5.78

The

fact

tha

t th

e th

erap

eutic

set

ting

is in

Bec

ause

I go

to

Blan

k's (

nam

e of

pro

-

7.11

th

e pr

ofes

sion

al's

offic

e.

fess

iona

l) of

fice.

peut

ic s

ettin

g is

in th

e ch

ild's

en-

viro

nmen

t.

prof

essi

onal

) to

pla

ces

near

whe

re I

live

.

The

fact

that

the

nonp

rofe

ssio

nal

ther

a-

4.33

Bec

ause

I go

with

Bla

nk (

nam

e of

non-

7.00

3.09

9.00

4.36

9.18

3.73

5.00

5.

00

3.36

4.

08

3.91

* 6.

86

0,

4.w

4.

74

8.67

8.

19*

6.36

5.

10

'Hig

her

mea

n scores a

re in

dica

tive

of lo

wer

rank

ing.

*p

< .0

5.

w

w

\o

340 H E R B E R T H A R A K I , K A R E N MOSEY, A N D P A T R I C I A S H E E D Y

and educative way (statement #4) as of the highest importance to the child’s progress. At the same time, the following were viewed as least important considerations for the child’s progress: the lay status of the nonprofessional (statement #2) and the office setting of the professional (statement #9). Because of the interaction effect, however, the exact mean- ing of the above main effect findings remains somewhat unclear. On the other hand, Tukey’s multiple comparison (Linton & Gallo, 1975, pp. 316-3 19) showed significant differences between groups: The children considered the status of the professional (state- ment #7) significantly more important than did both the professionals and the non- professionals; while the professionals considered their own role of “being a professional” (statement # I ) to be a more important variable than did the children and the non- professionals.

Discussio~ This study had two major purposes: first, to test specific hypotheses of role percep-

tion and, second, to gain a greater understanding of the participants’ perception of the various elements constituting the respective roles of professional and nonprofessional therapists. The results indicated support for two of the three hypotheses, namely, that the professionals would tend to overestimate their own role performance, and that the children would tend to selectively value different aspects of each type of therapy. The childrens’ judgments were selective but nevertheless balanced-i.e., they did not rank one type of therapy over the other as more important (see Table I ) . This was a remarkable accomplishment since the experimental manipulation had made it virtually impossible for them to exercise such impartiality deliberately. The childrens’ balanced views, in con- trast to that of the therapists who inflated their own role importance, may not necessarily indicate that “the client knows best”-but they do provide some food for thought.

The third hypothesis which predicted that the nonprofessionals would underestimate the importance of their own role, was not supported. In fact, they rated their own role as significantly more important than that of the professional’s. Our initial thought was to attribute these findings to cognitive dissonance (Festinger, 1954). Since the measures were taken at the conclusion of their nonprofessional experience, the displayed role infla- tion may have reflected the nonprofessionals’ attempts to justify their considerable work and efforts for which they received no financial reimbursement. The brouble with cognitive dissonance theory, however, is that it thrives on post-hoc reasoning. By the same token, for example, it could be possible to explain the professionals’ inflation of their role by suggesting that being paid for what was essentially routine outpatient work caused them dissonance, which in turn led to unwarranted attributions of importance to what they were doing. Our view is that the experiences which the nonprofessional students had accumulated as members of the companionship program could at least par- tially account for the inflation of their own role. These experiences could have bolstered their personal self-esteem since their unique therapeutic contributions were stressed throughout their training and supervision, and competitive feelings toward professional therapists were discouraged. Unfortunately, the only way to have established the nature of the students’ self-esteem in their nonprofessional role compared with that of the professional would have called for pre- and post-training assessments. As an addendum to this study, we decided to collect rankings from inexperienced nonprofessionals, i.e., students who had entered the companionship therapy program subsequent to the ter- mination of the present study. The results of a re-analysis of the data strengthened our

V A L U E S AND ROLES 34 I

belief that the nonprofessionals would perceive their own role in an increasingly favorable light as they continued in the program.’

I n terms of further understanding the various role aspects of the therapeutic relationship, the significant disparity between the children and their therapists concern- ing their view of the professional’s directive role (statement #7) is particularly meaningful. It could reflect the general acceptable aversion among therapists to be perceived as directive and manipulative. On the other hand, it could very well be in- dicative of a genuine need for structured guidance among children in therapy. Closely related to this viewpoint are the higher rankings among the professionals for their “being-a-professional” role (statement #l). Apparently both professionals and their children-clients believe that something in the title of “professional” is an important com- ponent of the therapeutic process.

Increased understanding was also seen in the higher overall rating by all groups for the supportive and educative function of the nonprofessional (statement #4). This finding has some implications for those who are involved in work with nonprofessionals. It suggests that nonprofessionals, through their work within the childrens’ environment, are in a unique position to directly observe troublesome interpersonal relationships and other problems that may not come to the attention of the professional in the traditional office setting. Furthermore, it appears that nonprofessionals can make their greatest contribu- tion by educating the patient in socially acceptable behaviors, and by providing suppor- tive friendship in areas where professionals cannot.

The limitations of this study are several. For example, a larger number of par- ticipants was needed, and the sex and status of the therapists should have been con- trolled. While it was possible to randomly choose and assign persons for this study, the applied settings did not allow for other controls. A matter of central importance is the impossibility of knowing how important professionals or nonprofessionals actually were, since the data were subjective judgments. For example, one might argue that the children’s judgment of what is important could not safely be taken as the standard. But then again, the question arises whether “subjective” role perceptions by therapists are in any way different in kind from their diagnostic labelling or selected courses of therapy. At least from a social-psychological perspective, these perceptions can be described as reflecting certain realities of the clinical milieu.

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‘A 4 X 2 mixed analysis (professionals, untrained nonprofessionals, trained nonprofessionals, and children-clients as the between factor; and professional therapy and nonprofessional therapy as within factors) showed a main effect for type of therapy, F ( I , 43) = 12.97. p < ,001; and a group membership X type of therapy interaction. F(3.43) = 1 3 . 5 3 , ~ < ,001. Subsequent specific comparisons with Duncan’s multiple range test (higher mean scores being indicative of lower ranking) showed that the inexperienced nonprofessionals viewed their own role as less important (M = 5.16) than that of their experienced countcrparts ( M = 4.0).

342 H E R B E R T H A R A R I , K A R E N MOSEY, A N D P A T R I C I A S H E E D Y

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