NO. 1981 Scaling Community Attitudes Toward the Mentally IIIcontact with the mentally ill and mental...

VOL 7, NO. 2, 1981 Scaling Community AttitudesToward the Mentally III

by S. Martin Taylorand Michael J. Dear

Abstract

The measurement of public at-titudes toward the mentally ill hastaken on new significance sincethe introduction of community-based mental health care. Previousattitude scales have been con-structed and applied primarily ina professional context. This articlediscusses the development andapplication of a new set of fourscales explicitly designed tomeasure community attitudes to-ward the mentally ill. The scalesrepresent dimensions included inprevious instruments, specif-ically, authoritarianism, benevo-lence, social restrictiveness, andcommunity mental health ideol-ogy, but are expressed in terms ofan almost completely new set ofitems that emphasize communitycontact with the mentally ill andmental health facilities. Data froma study of community attitudesabout neighborhood mental healthfacilities in Toronto are used totest the internal and external val-idity of the scales. Results of theanalysis provide strong supportfor the validity of the scales anddemonstrate their usefulness asexplanatory and predictive vari-ables for studying community re-sponse to mental health facilities.

In both America and Canada, themove toward community-basedmental health care has caused ex-tensive neighborhood opposition.The media often seem to delight inreporting the negative aspects ofcommunity care, such as erraticclient behavior or residents' fear ofproperty value decline. Geo- •graphical interest in this topicstems from two sources: first, be-cause citizen opposition can block

the siting of a mental health facil-ity, and thereby upset the patternof client accessibility to a decen-tralized service system; and sec-ondly, because proximity to mentalhealth centers apparently inten-sifies opposition, leading to spatialvariation in community cognitionand perception of facilities.

The purpose of this article is toprovide an instrument for the sys-tematic description of communityattitudes toward the mentally ill.Previous research has suggestedthat the social reintegration of ex-psychiatric patients depends cru-cially upon their acceptance (orrejection) by the host community.Accordingly, we wish to developscales to measure Community At-titudes Toward the Mentally 111,which will aid in the assessmentand prediction of the host commu-nity's reactions. In order to achieveits purpose, the article first re-views existing approaches to thestudy of attitudes toward the men-tally ill. Secondly, the sampleframe and data base for this studyare briefly outlined. Thirdly, thedevelopment of the scales is de-scribed, and their validity andutility in predicting communityreaction are demonstrated. Finally,some comments on the future ap-plications of the scales are offered.

Existing Studies of AttitudesToward the Mentally III

Geographical interest in mentalhealth care delivery has expandedrapidly during the past decade. Al-though Smith (1977) has outlinedthe broad areas of concern in this

Reprint requests should be sent toDr. S.M. Taylor, Dept. of Geography,McMaster University, Hamilton, Ont.,Canada L8S 4K1.

226 SCHIZOPHRENIA BULLETIN

field, research efforts are only nowbecoming more coordinated andpurposeful. Five themes seem tobe gaining prominence in the geo-graphic literature:

• Descriptions of the geograph-ical incidence of mental illness,and its ecological correlates (e.g.,Giggs 1973 and Miller 1974).

• Studies in the utilization andaccessibility of mental health serv-ices (Dear 1977a; Holton, Krame,and New 1973; Smith 1976; Joseph1979).

• Followup studies of the after-care problems of patients dis-charged from psychiatric hospitals(Smith 1975; Wolpert and Wolpert1976; Dear 1977b).

• Analyses of neighborhood op-position to the location of commu-nity mental health facilities (Wol-pert, Dear, and Crawford 1975;Boeckh, Dear, and Taylor 1980).

• Structural analyses of thecommunity support system for thementally disabled and otherservice-dependent populations(Gonen 1977; White 1979; Wolpert1978; Wolch 1979).

The approach taken in this arti-cle derives from the fourth of thesethemes, but also integrates twoother research themes from thepsychiatric literature. The first isthe substantive documentation ofattitudes toward the mentally ill;and the second is the methodolog-ical literature on attitude meas-urement. Because both these fieldshave been extensively reviewedelsewhere, our purpose here ismerely to indicate the major an-tecedents of our approach.

In the first instance, our work isindebted to the major synthesis onattitudinal research provided byRabkin (see, for example, Rabkin1974). She has recorded the in-

creasing volume of research since1945 on community attitudes, andhas recently warned that thesteady improvement in communityattitudes may have reached a"plateau," and that current trendsin deinstitutionalization maythreaten a decline in acceptance(Rabkin 1980). Closely related tothis work is the research of Segaland his associates into the dimen-sions of accepting and rejectinghost communities. In an extensiveseries of reports, Segal hassuggested that the reintegration ofthe mentally ill is closely linked tothe characteristics of the hostcommunity, of the facility itself,and of its residents (Segal and Av-iram 1978). Facilities with thehighest level of integration tend tobe in neighborhoods with low so-cial cohesion (e.g., downtownareas, with a highly transientpopulation). On the other hand,social integration tends to be lowerin highly cohesive neighborhoods(e.g., suburban single-family sub-divisions), which tend to closeranks against the incursion of thementally ill (Trute and Segal 1976).

Against this background of ac-ceptance or rejection and integra-tion or exclusion, we searched asecond literature in order to de-velop a scaling instrument forcommunity attitudes. While thereexisted several different scaling in-struments for measuring profes-sional attitudes toward the men-tally ill, very little effort appears tohave been made to develop suchinstruments for assessing commu-nity attitudes. Accordingly, weused the two most comprehensiveand best-validated of existingscales, the Opinions about MentalIllness (OMI) and CommunityMental Health Ideology (CMHI)scales, and adapted them to de-

velop our Community AttitudesToward the Mentally III (CAMI)scales.

The OMI scales were originallydeveloped in a study of the at-titudes of hospital personnel to-ward mental illness (Cohen andStruenin'g 1962). The OMI com-prises five Likert scales that wereempirically derived from factoranalysis of a pool of 100 opinionstatements. The statement poolwas compiled primarily to reflect arange of sentiments about mentalillness and the mentally ill, but italso drew upon existing scalessuch as the Custodial Mental Ill-ness Ideology Scale (Gilbert andLevinson 1956), the California Fscale (Adorno et al. 1950), andNunnally's (1961) multiple itemscale. The five OMI scales werelabeled as follows: authoritarianism,reflecting a view of the mentally illas an inferior class requiring coer-cive handling; benevolence, apaternalistic, sympathetic view ofpatients based on humanistic andreligious principles; mental hygieneideology, a medical model view ofmental illness as an illness like anyother; social restrictiveness, viewingthe mentally ill as a threat to soci-ety; and interpersonal etiology, re-flecting a belief that mental illnessarises from stresses in interper-sonal experience.

Baker and Schulberg (1967) de-veloped a multiple item scale de-signed specifically to measure anindividual's commitment to acommunity mental health ideol-ogy. The Community MentalHealth Ideology (CMHI) scalecomprises 38 opinion statementsexpressing three different aspectsof the basic ideology. The concep-tual categories focus on charac-teristics of the total population,rather than merely those seeking

VOL. 7, NO. 2, 1981 227

psychiatric help; primary preven-tion, including efforts via environ-mental intervention; and totalcommunity involvement in workingwith a variety of community re-sources to assist patients. The scalehas been shown to discriminate ef-fectively between groups known tobe highly oriented toward thisideology and random samples ofmental health professionals.

The OMI and CMHI scales werethe basis for measuring attitudestoward the mentally ill in the pres-ent study. They were substantiallyrevised with the dual objectives of(1) emphasizing community ratherthan professional attitudes towardthe mentally ill, and (2) reducingthe total number of items. Beforeproceeding with the developmentof the CAMI scales, we will outlinethe empirical framework of ourstudy.

A Survey of CommunityAttitudes in MetropolitanToronto

The major purpose of our studywas to analyze the basis for com-munity opposition to communitymental health facilities, with thetwin goals of determining thecharacteristics of "acceptor" and"rejector" neighborhoods and ofdeveloping planning guidelines forlocating those facilities (Dear andTaylor 1979). Data on attitudes andother resident characteristics wereobtained in 1978 by a questionnairesurvey of residents in MetropolitanToronto. A random sample wasselected from the total population .stratified by three levels of socio-economic status (high, medium,and low) and two levels of resi-dential location (city and suburb).Separate samples were drawn fromareas with and without existing

community mental health facilities.The total sample was 1,090 house-holds, 706 from areas without afacility and 384 from areas having afacility. Three types of facility wereincluded in the with-facility sam-ple: outpatient units, grouphomes, and social-therapeutic(drop-in) centers.

The questionnaire was intro-duced as a survey of attitudes to-ward community services; mentalhealth facilities were not men-tioned at the outset, and the firstthree questions asked for generalopinions. Subsequent questionselicited information on awarenessof neighborhood mental healthfacilities; attitudes toward thementally ill (using the CAMIscales); various perceptual, at-titudinal, and behavioral reactionsto facilities; and personal charac-teristics. Three parts of this ques-tionnaire are relevant here. First,all 1,090 respondents completedthe CAMI scaling instrument. Sec-ondly, they were asked to indicatethe desirability of having a poten-tial facility within three differentdistance zones from their resi-dence: within 1 block; 2-6 blocks;and 6-12 blocks. Respondent rat-ings were measured on a 9-pointlabeled scale ranging from "ex-tremely desirable" (1) to "ex-tremely undesirable" (9), with themidpoint (5) as "neutral." The be-havioral response of respondentsto the introduction of a facility intotheir neighborhood was also de-termined. Finally, all those re-spondents who were aware of anyfacility in their neighborhood (n =132, even though 384 respondentswere selected because they livedwithin one-quarter of a mile of afacility) were asked if they were infavor of, opposed to, or indifferenttoward it. Standard socioeconomic

and demographic data were alsocollected for each respondent.

It is important to point out thathighly specific labels were devisedfor use in the survey. Communitymental health facilities were definedfor the respondent as including

Outpatient clinics, drop-in cen-ters, and group homes which aresituated in residential neighbor-hoods and serve the local com-munity. Mental health facilitieswhich are part of a major hospi-tal are NOT included.

A similar precision was introducedin the definition of the mentally ill,who were characterized as

People needing treatment formental disorders but who arecapable of independent livingoutside a hospital.

This definition was used to em-phasize our focus on the nonhos-pitalized patient and to reflect thegeneral competence level of usersof community mental healthfacilities in the Toronto area.

Development of the CAMIScales

Scale Selection. Two related objec-tives directed the development ofscales to measure community at-titudes toward the mentally ill.The first was to construct an in-strument able to discriminate be-tween those individuals who ac-cept and those who reject the men-tally ill in their community. Thesecond was to develop scales topredict and explain communityreactions to local facilities servingthe needs of the mentally ill. Pre-vious research, as already dis-cussed, shows that attitudes to-ward mental illness are mul-tidimensional. Given our objec-tives, it did not seem necessary to


construct scales to measure allpossible dimensions but rather tofocus on those dimensions that arethe most strongly evaluative andhence best discriminate betweenthose positively and negativelydisposed toward the mentally illand mental health facilities. To thisend, we identified three of theOMI scales (authoritarianism, be-nevolence, and social restrictiveness)and the CMHI as the most usefulexisting scales for our purposes.

These four scales in their origi-nal form were not appropriate forour Toronto research for two rea-sons. First, the scales were de-veloped with professionals in mindas the potential respondents. Itwas therefore necessary to modifythem for use in a general popula-tion survey. Second, for some ofthe scales, the number of itemswas excessive for use in a commu-nity survey—particularly when, asin our case, many questions be-sides attitudes toward mental ill-ness were to be included in thequestionnaire. Scale constructionfor the Toronto study therefore es-sentially involved developing short-ened and revised versions of theoriginal scales to emphasize com-munity rather than professional at-titudes toward the mentally ill.

Item Pool. The item pool for pre-test purposes comprised 40 state-ments, 10 for each of the 4 scales.Only 7 of the 40 came from theoriginal OMI and CMHI scales:three for authoritarianism, two forbenevolence and social restrictiveness,and none for community mentalhealth ideology. Four additionalauthoritarianism items came fromthe Custodial Mental Illness Ideol-ogy Scale (CMI) developed by Gil-bert and Levinson (1956). For thethree OMI scales, the new state-

ments do not alter significantly thecontent domains of the scales asoriginally conceived by Cohen andStruening (1962). Their effect is toemphasize those facets of the con-tent domains which impinge mostdirectly on community contactwith the mentally ill. For theCMHI scale, the revisions are morefundamental because the originalstatements were clearly intendedfor application in a professionalcontext, and hence a completelynew set of statements was requiredfor community-based research.These new statements shift thefocus of the scale from the profes-sional's adherence to the generalprinciple of community mentalhealth, as emphasized in the Bakerand Schulberg scale, to the accept-ance by the general population ofmental health services and clientsin the community. The themes ex-pressed in the new scales aresummarized in the following de-scriptions.

Sentiments embedded in theauthoritarianism statements were:the need to hospitalize the men-tally ill (i.e., As soon as a personshows signs of mental disturbance,he should be hospitalized); the dif-ference between the mentally illand normal people (e.g., There issomething about the mentally illthat makes it easy to tell them fromnormal people); the importance ofcustodial care (e.g., Mental pa-tients need the same kind of con-trol and discipline as an untrainedchild); and the cause of mental ill-ness (e.g., The mentally ill are notto blame for their problems). Forbenevolence, the sentiments were:the responsibility of society for thementally ill (e.g., More tax moneyshould be spent on the care andtreatment of the mentally ill); theneed for sympathetic, kindly at-

titudes (e.g., The mentally ill havefor too long been the subject ofridicule); willingness to becomepersonally involved (e.g., It is bestto avoid anyone who has mentalproblems); and anticustodial feel-ings (e.g., Our mental hospitalsseem more like prisons than likeplaces where the mentally ill canbe cared for).

The social restrictiveness state-ments tapped the followingthemes: the dangerousness of thementally ill (e.g., The mentally illare a danger to themselves andthose around them); maintainingsocial distance (e.g., A womanwould be foolish to marry a manwho has suffered from mental ill-ness, even though he seems fullyrecovered); lack of responsibility(e.g., The mentally ill are very un-predictable and should not begiven any responsibility); and thenormality of the mentally ill (e.g.,Many people who have never hadpsychiatric treatment have moreserious mental problems thanmany mental patients). For theCMHI scale, statements expressedthese sentiments: the therapeuticvalue of the community (e.g., Thebest therapy for many mental pa-tients is to be part of a normalcommunity); the impact of mentalhealth facilities on residentialneighborhoods (e.g., Locatingmental health facilities in a resi-dential area downgrades theneighborhood); the danger to localresidents posed by the mentally ill(e.g., It is frightening to think ofpeople with mental problems liv-ing in residential neighborhoods);and acceptance of the principle ofdeinstitutionalized care (e.g., Men-tal hospitals have a very limitedrole to play in a civilized society).

Five of the 10 statements on eachscale expressed a positive senti-

VOL. 7, NO. 2, 1981 229

ment with reference to the under-lying concept, and the other fivewere negatively worded. Forexample for the authoritarianismscale, five statements expressed apro-authoritarian sentiment, andfive were anti-authoritarian. Theresponse format for each statementwas the standard Likert 5-pointlabeled scale: strongly agree/agree/neutral/disagree/stronglydisagree. The statements were se-quenced in 10 sets of 4, and withineach set, the statements were or-dered by scale—authoritarianism,benevolence, social restrictiveness,and community mental healthideology. The aim of this se-quencing was to minimize pos-sibilities of response set bias.

Pretest Results. Two separate pre-tests were conducted to assess thereliability and validity of thestatements and scales. The firstwas based on a group of first yearundergraduate students in urbangeography (n = 321) at McMasterUniversity and the second on therespondents (n = 54) in a field pre-test conducted by the York Univer-sity Survey Research Centre. For

both sets of data, item-total corre-lations and alpha coefficients werecalculated as measures of state-ment and scale reliability (Nun-nally 1967).

When the results from both pre-test samples (table 1) are consid-ered, the alpha coefficients for allfour scales are above .50, whichcan be regarded as a satisfactory(though modest) level of reliabilityin the early stages of scale con-struction. The coefficients are no-tably higher for the McMaster stu-dent group for three of the scales(except authoritarianism), whichhave relatively strong alphasabove .70.

Although the scales are in gen-eral satisfactory, inspection of thestatement-scale correlations showsa number of statements that makevery little contribution to theirparent scale. These statementswere replaced by statements ex-pressing similar sentiments tothose contained in statementsmore strongly correlated with totalscale scores. In addition, twostatements on the social restrictive-ness scale were replaced to elimi-nate unnecessary repetition.

Statement and Scale Reliabilityand Validity for Final Data. Thesame statistics were calculated totest the reliability and validity ofthe revised scales using the fullToronto data set (n = 1,090). Thealpha coefficients (table 1) are in allcases but one higher than the pre-test values, the one exceptionbeing on the benevolence scalewhere the coefficient for the finalscale is marginally lower than forthe McMaster pretest. Three of thefour scales have high reliability:CMHI (a = .88), social restrictive-ness (a = .80) and benevolence (a =.76). The coefficient for authori-tarianism (a = .68), though lower,is still satisfactory. These increasesin the alpha values reflect the gen-eral strengthening of the item-totalcorrelation for statements retainedfrom the pretest, and the im-provement due to the replacementof the statements shown to beweak in the pretest results.

The construct validity of thefinal scales was assessed by testingtheir empirical reproducibilityusing factor analysis. A four-factororthogonal solution accounting for42 percent of the variance was ob-

Table 1. Statement and scale reliabilities

Scale

AuthoritarianismBenevolenceSocial

restrictivenessCommunity mental

health ideology

Averageitem-scale r

McMaster1 York2

.27

.46

.38

.45

.29

.27

.40

.25

Final3

.34

.44

.47

.61

McMaster

.15-.44

.31-.59

.15-.57

.06-.70

Range ofitem-scale r

York

.03-.59

.10-.35

.23-.57

.06-.64

s

Final

.15-.45

.22-.53

.34-.63

.41-.76

Alphacoefficient

McMaster York

.58

.79

.70

.77

.62

.58

.59

.53

Final

.68

.76

.80

.88

'n = 321.'n = 54.»n = 1,090.


tained (table 2). Factor scores werecalculated and correlated with theraw scores on the four a prioriscales. The matrix of correlationsamong the a priori and factor scales(table 3) is revealing in two re-spects. First, it shows a high de-gree of intercorrelation among thea priori scales. The lowest correla-tion is -.63 between authoritar-ianism and benevolence, and

the highest is -.77 between socialrestrictiveness and CMH1. Thesecoefficients can in part be com-pared with those reported in pre-vious studies using the OMI (Frac-chi'a et al. 1972). In general, thecorrelations in this case are higher,possibly reflecting the fact that thedistinctions between the scales arenot so clear to the general popula-tion as they are to the profession-

Table 2. Factor structure for the final Community AttitudesToward Mentally III (CAMI) scales

als who were respondents in theearlier studies. More importantly,the difference may also reflect therevisions made to the scales forthis study.

The correlation matrix (table 3)shows secondly a reasonable de-gree of correspondence betweenthe a priori and factor scales—thedesired result from a constantvalidity standpoint. The CMHI

Statement Factor 1 Factor 2 Factor 3 Factor 4

Authoritarianism

One of the main causes of mental illness is a lack of self-discipline andwill power

The best way to handle the mentally ill is to keep them behind lockeddoors

There is something about the mentally ill that makes it easy to tell themfrom normal people

As soon as a person shows signs of mental disturbance, he should behospitalized

Mental patients need the same kind of control and discipline as a youngchild

Mental illness is an illness like any otherThe mentally ill should not be treated as outcasts of societyLess emphasis should be placed on protecting the public from the men-

tally illMental hospitals are an outdated means of treating the mentally illVirtually anyone can become mentally ill

Benevolence

The mentally ill have for too long been the subject of ridiculeMore tax money should be spent on the care and treatment of the men-

tally illWe need to adopt a far more tolerant attitude toward the mentally ill in

our societyOur mental hospitals seem more like prisons than like places where the

mentally ill can be cared forWe have a responsibility to provide the best possible care for the men-

tally illThe mentally ill don't deserve our sympathyThe mentally ill are a burden on societyIncreased spending on mental health services is a waste of tax dollarsThere are sufficient existing services for the mentally illIt is best to avoid anyone who has mental problems

.5V

.48

.52

55

51

.08

.21

.12

.03

.19

.18

.00

.13

08

07

2541283257

-.02

-.18

-.07

-.06

-.13

-.10-.25-.19

-.05-.11

.12

.21

.21

.06

.12

.08

.21

.22

.19

.21

-.24

-.26

-.09

.05

-.05

-.22-.34-.12

-.01-.33

.39.54

.51

.10

.60

.41.25.57.34.34

.00

.09

.12

.24

.16

.18

.22

.34

.47.25

-.35-.08

-.30

-.43

-.20

.02

.02

.04-.13-.04

VOL. 7, NO. 2, 1981 231

Statement Factor 1 Factor 2 Factor 3 Factor 4

Social restrictiveness

The mentally ill should not be given any responsibilityThe mentally ill should be isolated from the rest of the communityA woman would be foolish to marry a man who has suffered from mental

illness, even though he seems fully recoveredI would not want to live next door to someone who has been mentally illAnyone with a history of mental problems should be excluded from tak-

ing public officeThe mentally ill should not be denied their individual rightsMental patients should be encouraged to assume the responsibilities of

normal lifeNo one has the right to exclude the mentally ill from their neighborhoodThe mentally ill are far less of a danger than most people supposeMost women who were once patients in a mental hospital can be trusted

as babysitters

Community mental health ideology

Residents should accept the location of mental health facilities in theirneighborhood to serve the needs of the local community

The best therapy for many mental patients is to be part of a normalcommunity

As far as possible, mental health services should be provided throughcommunity based facilities

Locating mental health services in residential neighborhoods does notendanger local residents

Residents have nothing to fear from people coming into their neighbor-hood to obtain mental health services

Mental health facilities should be kept out of residential neighborhoodsLocal residents have good reason to resist the location of mental health

services in their neighborhoodHaving mental patients living within residential neighborhoods might be

good therapy but the risks to residents are too greatIt is frightening to think of people with mental problems living in resi-

dential neighborhoodsLocating mental health facilities in a residential area downgrades the

neighborhoodPercentage of variance accounted for by each factor

575552

5448

2312

152634

-.14-.32-.24

-.46-.20

-.15-.13

-.39-.22-.20

-.23-.10-.11

-.16-.12

-.22-.34

-.23-.14-.04

.16

.21

.06

.15

.17

.26

.30

.20.44.28

-.09

-.21

-.06

-.21

-.20

-.38-.39

-.52

-.56

-.37

28.1

.65

.37

.33

.58

.55

.67

.59

.45

.44

.56

5.5

.29

.23

.20

.16

.17

.22

.21

.12

.15

.22

4.2

-.16

-.30

-.35

-.29

-.23

-.10-.14

-.15

-.12

-.06

3.9

'Factor loadings > ± 40 are italicized.

scale is strongly identified with thesecond factor (r = .86), and the be-nevolence scale is almost as stronglyidentified with the third factor (r =.81). Authoritarianism and social re-strictiveness are approximatelyequally correlated with the firstfactor and, to a lesser extent, withthe fourth factor. This provides

some evidence that these twoscales perhaps represent a singledimension. They are treated sepa-rately, however, in the subsequentanalyses. The remaining coeffi-cients in the lower right of thematrix show the low correlationamong the factor scales. This is anartifact of the algorithm, which

forces independence between thefactors within an orthogonal solu-tion.

Correlates of AttitudesToward the Mentally III

The theoretical framework for theToronto study (Dear and Taylor


Table 3. Scale validities1

AuthoritarianismBenevolenceSocial

restrictivenessCommunity mental health

ideologyFactor 1Factor 2Factor 3Factor 4

AUTH BNVL

-.63—

SRST

.72- .65

—

CMHI

- .64.65

- .77

—

FACT1

.73- .45

.72

- .49—

FACT 2

- .25.33

- .49

.86- .13

—

FACT 3

- .34.81

- .32

.33- .07

.10—

FACT 4

.51- .31

.46

- .34.06

- .11- .12

—

1 Pearson correlation coefficients(n = 1,090).

1979, chapter 2) is that attitudestoward the mentally ill are a func-tion of a combination of personalcharacteristics includingsocioeconomic status, life cyclestate, and personal beliefs andvalues. Existing research on at-titudes toward the mentally illprovides some support for the im-portance of these factors (see Rab-kin 1974). The same theoreticalframework shows that attitudestoward the mentally ill are themajor influence on reactions tomental health facilities. The con-struct and predictive validity of theattitude scales within this theoreti-cal framework can therefore beexamined by analyzing their re-lationship with, on the one hand,various personal characteristicsand, on the other, measures of re-sponse to mental health facilities.

Personal Characteristics and At-titudes Toward the Mentally 111.Three subsets of personal charac-teristics were distinguished for thisanalysis: demographic, socio-economic, and belief variables.Demographic characteristics were

measured by four variables: sex,age, marital status, and number ofchildren in three age groups(under 6, 6 to 18, and over 18).Socioeconomic status was meas-ured in conventional terms byeducational level, occupationalstatus (both respondent and headof household) and household in-come, and in addition, by tenurestatus. Personal beliefs and valueswere not measured directly. Aproxy measure is included in termsof church attendance and denomi-national affiliation. Also includedas a factor affecting beliefs and at-titudes toward the mentally ill is ameasure of familiarity with mentalillness based on whether the re-spondent or his/her friends or rela-tives had ever used mental healthservices of any kind.

The variables used in the analy-sis represent different levels ofmeasurement—nominal, ordinal,and interval/ratio. The specificmeasurement properties of thepaired combination of variables de-termine the statistical test used.The CAMI scales are assumed tohave interval properties. Tests that

relate attitudes to populationcharacteristics with nominal prop-erties are based on a difference ofmeans test (t test) where thecharacteristic has two categories(e.g., sex), and a one-way analysisof variance (F test) where there aremore than two categories (e.g.,marital status). Relationships be-tween population characteristicsmeasured on an ordinal scale (e.g.,household income) and attitudestoward the mentally ill are tested

i by nonparametric correlation(Kendall's tau). Finally, relation-ships involving characteristics withinterval properties (e.g., age) aretested by parametric correlation(Pearson's r).

Five of the six demographic vari-ables examined show relativelystrong relationships with the fourattitude scales, the exception beingnumber of children over 18 (table4). Consistent with previousstudies, older residents report lesssympathetic attitudes toward thementally ill. This pattern occurs forall four scales. Older respondentsin the Toronto sample are in gen-eral more authoritarian, less be-

VOL. 7, NO. 2, 1981 233

Table 4. Demographic variables and attitudes toward the mentally ill

Attitude scales

Demographicvariables

Age'# Children < 6 1

# Children 6-181

# Children > 181

Sex2

Maritalstatus3

SocialAuthoritarianism Benevolence restrictiveness CMHI

.20**

.08**

.08**

.06*

2.65*

-.18*** .32*** - .21***-.09*-.09*-.03

-4.56*

.07** - . 11 *

.10" -.13*NS) .03 (NS) -.04

1.82 (NS) -3.02*

****(NS)*

["F = 36.2~| ("F = 21.2"| f F = 37.1~| I" F = 23.0~|IM = 35.4J IM = 22.5J IM = 36.4 J \_M = 24.2 J

10.87*Married =

Single =Widowed =Divorced =

Separated =

_ 6.12*35.337.133.737.236.3

Married =Single =

Widowed =Divorced =

Separated =

_ 16.42*** _ _ 12.13*= 22.3~f= 20.8= 22.2= 20.6= 20.5

Married = 36.0Single = 38.6

Widowed = 34.3Divorced = 38.3

Separated = 37.1

Married =Single =

Widowed =Divorced =

Separated =

24.521.724.321.921.9

Group means are shown in brackets.' Pearson's r.2f statistic.3F statistic.

""Significant at .001 level."Significant at .01 level.'Significant at .05 level.NS—Not significant at .05 level.

nevolent, more socially restrictive,and less community mental healthoriented in their views.

Stronger effects for sex arefound for these data than for re-sults reported in previous studies.The direction of the effect showsmore sympathetic attitudes amongfemale respondents. This emergeson three of the four scales. No sig-nificant difference occurs for socialrestrictiveness.

Highly significant differences arefound among marital status groupson all four scales. Examination ofthe group mean on each scale re-veals the pattern of the effect. Abasic distinction emerges betweenthe married and widowed groupsand those single, separated, ordivorced—the former expressingthe less sympathetic attitudes oneach of the four scales. These dif-

ferences in part reflect the agevariation already observed and theeffects of number and ages of chil-dren.

The number of children under 6years and the number between 5and 18 years show very similar ef-fects, the latter being marginallystronger. In both cases, re-spondents with children in theseage groups are generally more au-thoritarian and socially restrictiveand correspondingly less benevo-lent and community mental healthoriented. The lack of significant ef-fects for number of children over18 supports the expectation thatparents with older families willhave fewer concerns about thementally ill and their children'spossible contact with them.

Taken together, these results in-dicate that the effects of demo-

graphic characteristics on attitudestoward the mentally ill are bothstatistically significant and consist-ent in their direction. The variablesincluded here, excepting sex, rep-resent in combination a measure oflife-cycle status. The conclusion istherefore that attitudes toward thementally ill vary significantly bylife-cycle stage.

Four of the five socioeconomicmeasures show strong and consist-ent relationships with the attitudescales, the exception being house-hold income (table 5). The ob-served direction of the relation-ships confirms previous findings:more sympathetic attitudes arecharacteristic of higher status resi-dents. This conclusion applieswhen status is measured in eithereducational or occupational terms,though the relationships are


Table 5. Effects

Socioeconomtc

variables

Education1

Occupation(respondent)1

Occupation(head)1

Householdincome1

Tenure2

of socioeconomic variables on attitudes toward the mentally ill

Authoritarianism

-.27***

- .21***

-.19***

- .11***-3.64***

["Owners = 35.3~|[.Renters = 36.5j

Attitude

Benevolence

.17***

.09***

.08***

.03 (NS)4.60***

["Owners = 22.3~|[.Renters = 20.9j

i scales

Restrictiveness

-.22***

-.12***

-.10***

-.06**-5.25***

[Owners = 36.0~l[.Renters = 37.8J

CMHI

.16***

.08***

.08***

.01 (NS)7.35***

("Owners = 24.7"l[Renters = 21.9.J

Group means are shown in brackets.1 Kendall's tau2t statistic

"'Significant at .001 level."Significant at .01 level.

'Significant at .05 level.NS—Not significant at .05 level.

somewhat stronger for the educa-tion variable. Relationships withincome, the third conventionalmeasure of socioeconomic status,are weaker and for two scales, be-nevolence and CMHI, are not sig-nificant. This finding indicates thathousehold income varies some-what differently within the popu-lation than does education or occu-pation and that income is the leasteffective as a discriminator of at-titudes toward the mentally ill.

The significant effect of tenurestatus confirms the expectationthat owners generally hold lesssympathetic attitudes than renters,possibly reflecting their greatervested interest in protecting theirdaily life environment.

Within the subset of belief vari-ables, church attendance andfamiliarity with mental health careshow significant relationships withall four attitude scales (table 6).Religious denomination has a sig-nificant effect on only the au-thoritarianism and benevolencescales. The direction of the effect

for church attendance is that reg-ular attenders are, on average, lesssympathetic in their views, tend-ing to be more authoritarian andsocially restrictive and less be-nevolent and community mentalhealth oriented. As could be ex-pected, regular attenders in gen-eral hold more conservative views.Among attenders, however, thereare significant denominational dif-ferences for two of the scales. Ofthe 13 major denominationalgroups distinguished in the sur-vey, the Pentecostal and Greek Or-thodox groups emerge as the mostauthoritarian in contrast to theBaptists and Salvation Army, whoexpressed the least authoritarianviews. Correspondingly, the Bap-tist, together with United Church,adherents held the most benevo-lent attitudes, again in contrast tothe least benevolent views of thePentecostal and Greek Orthodoxmembers.

In terms of familiarity with men-tal health care, respondents who

themselves had used mental healthservices or whose friends or rela-tives had used them expressedmore sympathetic attitudes on allfour scales. Personal experience ofmental health care, whether director indirect, therefore has a signifi-cant effect on subsequent attitudestoward the mentally ill and theprovision of mental health serv-ices.

Considered overall, the patternof these relationships provides fur-ther support for the construct val-idity of the attitude scales. The re-lationships are consistent with thehypotheses derived from the un-derlying theoretical frameworkand are also similar to those re-ported in previous studies inwhich the personal correlates of at-titudes toward the mentally illhave been examined. These re-sults, however, go beyond thosepreviously reported in that abroader range of personal charac-teristics was included in theanalysis.

VOL. 7, NO. 2, 1981 235

Table 6. Effects of

Beliefvariables

Church attendance1

Religiousdenomination2

Familiaritywith mentalhealth care1

belief variables on attitudes toward the mentally

Attitude scales

Authoritarianism Benevolence

6.07*** -3.02**I" No =36.5] [No = 21.41|_Yes = 34.7J [Yes = 22.3J

3.97*** _ 2.28**Anglican = 36.2

Baptist = 36.9Greek Orthodox = 30.5

Jewish = 35.6Lutheran = 33.5

Mennonite = 37.0Pentecostal = 27.3

Presbyterian = 35.5Roman Catholic = 34.1Salvation Army = 37.0

Ukrainian Catholic = 34.9United = 36.8Other = 32.8

Anglican = 21.7Baptist = 20.1

Greek Orthodox = 26.2Jewish = 21.1

Lutheran = 22.4Mennonite = 23.0

Pentecostal = 21.3Presbyterian = 21.6

Roman Catholic = 22.9Salvation Army = 21.7

Ukrainian Catholic = 21.9United = 20.8Other = 23.6

-9.23*** 8.25***[ No = 34.6] [ No = 22.8]LYes = 37.6J [Yes = 20.4J

' ill

Restrictiveness CMHI

5.53*** -4.27**[ No = 37.5] [No = 22.9][Yes = 35.6J [Yes = 24.6j

1.49 (NS) 1.07 (NS)

-10.09*** 8.72***[ No = 35.4] [No = 24.9]LYes = 38.7J LYes = 21.6j

Group means are shown in brackets.U statistic.2F statistic.

Attitudes Toward the Mentally 111and Reactions to Mental HealthFacilities. The relationship be-tween attitudes toward the men-tally ill and reactions to mentalhealth facilities can be dealt withmore briefly because we have dis-cussed them in detail elsewhere(Taylor et al. 1979). The purposeof examining these relationships inthe context of this article is to es-tablish the predictive validity ofthe four scales.

For this analysis, reactions tofacilities were measured in both at-titudinal and behavioral terms. All

'"Significant at .001 level."Significant at .01 level.

of the Toronto respondents(n = 1,090) rated the desirability ofhaving a hypothetical facility lo-cated within three different dis-tances of their home: within 1block, 2 to 6 blocks, and 7 to 12blocks. Ratings were on a 9-pointlabeled scale ranging from "ex-tremely desirable" to "extremelyundesirable." For each facility-distance combination rated to anydegree undesirable, respondentswere asked what, if any, actionthey would most likely take in op-position. They were shown a list ofnine possible actions (table 7). Re-

* Significant at .05 level.NS—Not significant at .05 level.

spondents aware of an existingfacility in their neighborhood wereasked whether they were in favorof, opposed to, or indifferent to-ward it. If opposed, they wereasked, using the same list, whatactions they had taken. It is re-vealing that only 132 respondentswere aware of a facility in theirneighborhood, even through 384were selected on the basis of livingwithin a quarter mile of one.

The general hypothesis thatreactions to facilities are related toattitudes toward the mentally illwas tested first by correlating


Table 7. Behavioral intentions scale

NothingIndividual

action

Group action

Move

1. Oppose and do nothing2. Oppose and write to newspaper3. Oppose and contact politician4. Oppose and contact other government official5. Oppose and sign petition6. Oppose and attend meeting7. Oppose and join protest group8. Oppose and form protest group9. Oppose and consider moving

scores on the four scales with thefacility desirability ratings for thethree distance zones. The correla-tions (table 8) show highly signifi-cant relationships between all fourscales and the three separate de-sirability ratings. Considered byattitude scale, the highest coeffi-cient occurs for CMHI—the scalemost directly concerned withcommunity mental health. Thepositive sign of the coefficients forCMHI is consistent with thehypothesis that facility locationswill be judged more desirable bythose expressing pro- CMHI senti-ments.

After CMHI, the scale moststrongly correlated with the de-

sirability ratings is social restrictive-ness. This scale expresses the viewthat the mentally ill pose a threatto society and that their activitiesshould therefore be closely con-trolled and supervised. Thoseholding a pro-social restrictivenessview would be predicted as judg-ing neighborhood mental healthfacilities as undesirable, and this isconfirmed by the negative signs ofthe coefficients. The coefficientsfor authoritarianism and benevolenceare slightly lower, but their signsconfirm the working hypotheses.Pro-authoritarian views are as-sociated with less favorable ratingsof facilities, and pro-benevolentsentiments coincide with morefavorable ratings.

Table 8. Relationships1 between attitudes and judgeddesirability of potential facility

Scale

AuthoritarianismBenevolenceSocial restrictivenessCommunity mental health ideology

7-12 blocks

-.28.33

-.34.45

Distance zone

2-6 blocks <1

-.36.36

-.44.57

block

-.40.40

-.48.61

1 Pearson correlation coefficients. All coefficients are significant beyond .001 level.

Considered by distance zone,the correlations again show a con-sistent pattern. For each scale, thecoefficients increase with decreas-ing distance. This suggests that thevariation in desirability ratings be-comes increasingly systematic asthe distance between facility andresidence decreases. As a result,attitudes toward the mentally illbest predict the judged desirabilityof facility locations within a blockof home.

For the analysis of relationshipsbetween attitudes toward the men-tally ill and intended opposition tofacilities, the nine possible actionswere reduced to four categories: noaction, individual action, group ac-tion, and consider moving (table8). The pattern of the relationshipsfrom the analyses of variance(table 9) is similar to that just de-scribed for the desirability ratings.The relationships are strongest forCMHI and for the nearest distancezone. None of the four scales aresignificantly related to intendedactions for the 7-12 block zone.For the other two zones, benevo-lence is the only scale that is notsignificantly related.

Examining the mean scale scoresfor the four categories of intendedaction reveals the pattern of thesignificant relationships. Forexample, in the case of the re-lationship with CMHI for thenearest distance zone, those in-tending no action are on averagethe most pro-CMH7, followed inorder of describing communitymental health orientation by thoseintending a group action, those in-tending an individual action, andthose who would consider moving.The fact that the most communitymental health oriented would donothing, and the least so wouldconsider moving, provides further

VOL. 7, NO. 2, 1981 237

Table 9. Relationships1 between attitudes and behavioral intentions

Distance zones

Scale7-12 blocks

(n =128)2-6 blocks(n = 255)

< 1 block(n = 404)

Authoritarianism

BenevolenceSocial restrictiveness


.74 (NS)

.56 (NS)

.91 (NS)

1.87 (NS)

4.09**Nothing = 34.3

Individual action = 32.2Group action = 32.9

Move = 30.91.12 (NS)

2.63*Nothing = 34.4


Move = 31.17.23*** ~_Nothing = 27.0


Move = 31.9

9.86***Nothing =34.1


Move = 31.42.03 (NS)12.24***

Nothing = 35.o"Individual action = 34.7

Group action = 34.8Move = 31.0

• 14.51*** ZNothing = 26.0


Move = 31.3

Group means are shown in brackets.1 Figures shown are F statistics.NS— F probability > .05.

support for the predictive validityof the CMHI scale. The ordering ofthe category means is equally con-sistent for the other two scaleshaving significant relationshipswith intended action. For example,the category means on social re-strictiveness, again for the nearestdistance zone, show those whowould consider moving as holdingthe most socially restrictive at-titudes, followed by those intend-ing individual action, group ac-tion, and no action—the exact re-verse of the ordering observed forthe CMHI scale.

A final analysis of variance wasperformed to test the relationshipsbetween the four attitude scalesand attitudes toward existingfacilities. The respondents whowere aware of a facility (n = 132)

"F probability < .05."F probability < .01."'F probability < .001.

were classified into three groups:in favor of (n = 95); indifferenttoward (n = 19); and opposed to( n =18). Mean scores on each ofthe attitude scales were signifi-cantly different for the threegroups (table 10). Relationships areagain strongest for CMHI followedby social restrictiveness, benevolence,and authoritarianism. For CMHIand benevolence, the highest meanscores are for the "in favor" group,and the lowest means are for the"opposed" group. The reverseholds for the authoritarianism andsocial restrictiveness scales.

The strength, direction, andconsistency of the relationships be-tween the attitude scales and thedifferent measures of response tohypothetical and existing mentalhealth facilities provide strong

evidence for the predictive validityof all four scales. For each of theresponse variables, the strongestvalidation occurs for the CMHIscale—a finding that is to be ex-pected, and indeed hoped for,given the explicit community em-phasis of this dimension of at-titudes toward the mentally ill.Similarly, the repeated emergenceof social restrictiveness as the sec-ond most powerful predictor isconsistent with the content domainfor that scale, which emphasizesthe potential dangerousness of thementally ill and the importance ofmaintaining social distance fromthem. The weaker predictivepower for the benevolence scale,most apparent for the relationshipswith intended opposition tofacilities, suggests a transcendent


sympathetic attitude toward thementally ill, which conceals impor-tant attitudinal variations exposedby the other scales. Taken to-gether, these results are very en-couraging not only in terms ofscale validation but also in terms oftheir potential usefulness in futurestudies of community attitudestoward the mentally ill and mentalhealth facilities.

Conclusions

In the Toronto study, the de-velopment of scales to measurecommunity attitudes toward thementally ill originated in the geo-graphic problem of explaining spa-tial variations in public response tomental health facilities. Fourexisting scales were the basis forconstructing a new set of scalesrepresenting the following fourdimensions of community at-titudes: authoritarianism, benevo-lence, social restrictiveness, andcommunity mental health ideology.These scales differ from the origi-nals in two main respects: first, bytheir emphasis on those facets ofthe content domain of each scalethat relate most directly to com-munity contact with the mentallyill; and second, by the statements'being worded with a general pub-lic rather than professional samplein mind.

The internal and external valid-ity of the CAMI scales was exten-sively analyzed using both the pre-test and final data sets for the To-ronto study. Weak items identifiedin the pretest were replaced beforethe major data collection phase.High levels of internal validitywere shown for the final scalesbased on item-scale correlations,alpha coefficients, and factor anal-ysis. External validity was exam-

Table 10. Relationships1 between attitudes and reactions toexisting facility2

Scale Reaction to facility

Authoritarianism

Benevolence

Social restrictiveness


8.58***Favor =

Oppose =Indifferent =

9.81***f Favor = ;

Oppose = :[indifferent = ;

12.94***Favor =

Oppose =:Indifferent = :

21.94***I" Favor = ;

Oppose = ;[indifferent = ;

Group means are shown in brackets.'Figures are F statistics.2 Analysis based on respondents aware of a facility in their neighborhood (n = 132).'"F probability < .001.

ined in two ways within thetheoretical framework for the To-ronto study. Construct validitywas assessed by analyzing re-lationships between the attitudescales and a range of personalcharacteristics. Predictive validitywas tested by analyzing relation-ships between the scales and vari-ous measures of response to men-tal health facilities. In both cases,the strength, direction, and consis-tency of the relationships providedstrong support for the externalvalidity of the CAMI scales.

The theoretical and practical sig-nificance of the CAMI scales is welldemonstrated in the Toronto studywhere these measures of attitudestoward the mentally ill are basic tothe explanation and prediction ofindividual and community re-sponses to mental health facilities

(Dear and Taylor 1979). It remainsfor future studies to establish theapplicability of the CAMI scalesbeyond the Toronto situation, al-though there is no a priori basis forquestioning their generalizability.

The Toronto study is cross-sectional and provides no basis forestablishing how sensitive thescales might be as indices of at-titude change. It is planned to usethe same scales in a study of com-munity attitudes before and afterthe opening of a neighborhoodmental health facility. This will in-troduce a longitudinal dimensionwhereby changes in attitude can bemonitored and the usefulness ofthe scales for monitoring changescan be established.

The Toronto data provide only alimited basis for analyzingattitude-behavior relationships. As

VOL. 7, NO. 2, 1981 239

reported here, the scales arestrongly related to behavioral in-tentions; the link with actual be-havior remains uncertain, since sofew of the Toronto respondentshad actually taken any action tooppose a mental health facility. Afocus for a future study is there-fore to examine the predictivevalidity of the scales for actual be-havior with respect to both thementally ill and the mental healthfacilities.

The shift to community basedmental health care emphasizes theneed for reliable and validmethods for measuring public at-titudes toward the mentally ill.The CAMI scales discussed in thisarticle represent an attempt to de-velop such a method, and it ishoped that use of the scales insubsequent studies will further es-tablish their validity. •

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Acknowledgment

The research reported was sup-ported by Grant No. 410-77-0322of the Social Science andHumanities Research Council ofCanada.

The Authors

Dr. S.M. Taylor holds a Ph.D. ingeography from the University ofBritish Columbia, and Dr. M.J.Dear, a Ph.D. in regional sciencefrom the University of Pennsyl-vania. Both are presently AssociateProfessors in the Department ofGeography at McMaster Universityin Hamilton, Ontario, Canada.

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