The Public Perception of Mental Health Professions: An Empirical Examination.

This study examined the public's confidence in clinical psychologists, psychiatrists, master's-level counselors, doctoral-level counselors, and social workers by ranking confidence levels across five case vignettes of various severity. While the exploration of professional identity is a necessary task for all mental health disciplines, counseling has lagged behind psychology and psychiatry in exploring the issue of professional identity from the prospective of the client-consumer. Results indicated that doctoral-level counselors were perceived similarly to clinical psychologists across all cases and were preferred in every case over master's-level counselors. Overall, the public sampled was confident in LPCs' ability to treat less severe cases and less confident in their ability to treat serious psychiatric disorders.

The search for an identity within any profession is a necessary task, but it is often characterized by confusion, frustration, and ambiguity. The professions falling under the umbrella of mental health providers are a diverse group with a variety of training standards, licenses, specialties, philosophies, and histories. Despite this diversity, there seems to be considerable overlap in the types of clients served and services provided (Hanna & Bemak, 1997). As each mental health profession struggles to find a significant place to ensure financial survival in an economy of shrinking funds for mental health, the need for a unique identity becomes that much more crucial.

Counselors initiated the identity process by attempting to answer the question, "What is a counselor?" through discussion between counselors. A few articles from counselor-related journals focus on the ongoing debate among counselors regarding the issue of professional identity without any conclusive comments on the nature of the identity of a counselor (Hanna & Bemak, 1997; Maples, Altekruse, & Testa, 1993; Peer, 1980; Ritchie, 1990; Seiler & Messina, 1979).

Other mental health professions have dedicated much of the their recent history to research, exploring the nature of their respective professional identities. Psychiatrists and psychologists (counseling and clinical) devoted years of effort to internally define their profession, though they achieved limited success (Bales, 1984; Beitman, 1983; Benjamin, 1986; Bevan, 1976; Fein, 1954; Fishman & Neigher, 1982; Newman, 1957; Zytowski, Casas, Gilbert, Lent, & Simon, 1988). Interestingly, the internal debate among these professions seems to remain at the confusion stage, not unlike recent attempts made by counselors. If the professions themselves are uncertain about identity issues, think of the confusion the public must face when trying to choose among the various disciplines.

Beyond the strategy of attempting to internally define a profession, psychologists have empirically investigated identity by exploring the public's evaluation of mental health professions. By attending to the opinions of the consumer, the results of the research have provided some useful indicators of preferences for and distinctions among mental health professionals as viewed though the eyes of the public. This strategy seems particularly timely as mental health professionals compete for visibility and acceptance by the paying public as insurance benefits for mental health care decrease. Wollersheim and Walsh (1993) succinctly sum up the necessity of the business marketing shift of mental health care, "To reach consumers effectively, it is essential to understand their existing attitudes toward the commodity being marketed" (p. 171).

Early efforts by psychology researchers focused on exploring the public's ability to differentiate between psychologists and psychiatrists. Grossack (1954) interviewed 51 African-Americans in the southern region of the United States and discovered that a large proportion of that sample had difficulty discriminating between a psychologist and a psychiatrist. Nunnally and Kittross (1958) improved on the Grossack study by sampling 207 members of a community in Illinois. The survey included medical professions not associated with mental health (doctor, nurse, physician) and traditional mental health professions (psychiatrist, psychologist, social worker). Like Grossack, this study concluded that there was no distinction made, in terms of attitude, between psychiatrists and psychologists. Later studies, using the general public and undergraduate psychology students, also confirmed the blurred identity between psychologists and psychiatrists (Tallent & Reiss, 1959; Thumin & Zebelman, 1967).

In 1979, McGuire and Borowy sought to replicate the Nunnally and Kittross (1958) study using undergraduate psychology students. This study also marked the first time that the profession marriage counselor was included and compared to other mental health professions such as psychiatrist, clinical psychologist, counseling psychologist, school psychologist, and social worker. On measures of value and understandability about the professions, marriage counselor ranked last in both categories. McGuire and Borowy explained that the low opinion of marriage counselors may be due to "the wide disparity in the credentials of its practitioners" (p.78).

Webb and Speer (1986) criticized the past studies on public image for the limited nature of the semantic differential, fixed choice method for assessing attitudes. Webb and Speer utilized a multiple-stage study that ultimately assessed the attitudes of undergraduate students and their parents toward the professions psychiatrist, psychologist, counselor, physician, scientist, and teacher along the factors of favorability and severity of cases treated. On the factor of favorability, counselors were fourth in the order, behind psychiatrists, psychologists, and physicians. While psychiatrists and psychologists were rated as dealing with the most severe cases, counselors were viewed as dealing with a more normal population.

Two recent studies have sought to further investigate psychology's public image and have included counselors. Webb (1989) used a small sample of undergraduate students to assess the public image of the six professions used in the Webb and Speer (1986) study. Webb used three methods of study: subject generated descriptive paragraphs, an Adjective Generation Technique (AGT), and a Likert scale to measure favorability. Webb reported that the public image was similar to the Webb and Speer (1986) findings for the descriptive paragraph, the only exception being that counselor moved ahead of physician. For the AGT, counselors were ranked highest, and the Likert scale for favorability ranked counselors second only to teachers. Although the researcher criticized the low reliability across the methods, this study points to the first positive report on counselors' public image.

Warner and Bradley (1991) added a case study element to the assessment of public image of master's-level counselors, doctoral-level clinical psychologists, and psychiatrists. In this study, 120 undergraduate students answered a multiple choice test of training requirements (assessing knowledge), a rating of personal qualities (assessing attitudes), and a rating of confidence in the clinicians to treat five clinical problems of various severity using vignettes adapted from Spitzer, Skokol, Gibbon, and Williams (1981). Overall the sample's knowledge about the profession was small, with the average subject only answering 6 of the 12 questions correctly. The personal qualities most associated with counselors when compared to the other professions included helpful, caring friendly, necessary, and underpaid. The case-confidence ratings produced some positive results for counselors. For the one case rated most severe and involving the use of medication (psychotic depression), psychiatrists were rated higher than psychologists, who were rated higher than counselors. However in three of the cases (avoidant personality disorder, marital problem, and adjustment disorder with depressed mood), counselors were either the therapist of choice or equally preferred with psychiatrists.

Most recently, Wollersheim and Walsh (1993) applied the methodology of Warner and Bradley (1991) to members of a northwestern community. On the assessment of knowledge, the study reported that students were less knowledgeable than other community members about the professions. The reported results on attitude toward counselors did not differ much from the previous study. Using slightly different case studies, the nonstudent sample preferred counselors over psychologists and psychiatrists on only one case (marital problem). The three cases that represented higher levels of severity (PTSD, psychotic depression, and borderline personality disorder) showed a significant preference for psychiatrists over psychologists, with counselors rating a distant third. On the case of adjustment disorder with academic inhibition, psychologists were preferred over the equally preferred psychiatrists and counselors.

Although Wollersheim and Walsh (1993) conclude that psychologists must be more vigilant in educating the public concerning the strengths of psychology or risk being squeezed out of the market, this study and the numerous others demonstrate an equal need on the part of counselors to inform the public about the uniqueness of the counseling profession. Because the research conducted by psychologists is designed to answer specific questions regarding psychology, counselors are either left out of such studies or such research does not include the broad range of mental health professionals that may influence the public's opinion to see a counselor (for example, social workers). Even among psychology-oriented studies that include counselors, the design fails to distinguish between master's-level and doctoral-level counselors.

Where is the interest in public image by counselors? Unfortunately, the counseling literature remains focused on the internal debate of identity. The purpose of this study is to address the public's perception of mental health professionals with an emphasis on including issues that are important to assessing the public's image of licensed professional counselors. Specifically, the study addresses public opinion in the areas of knowledge about the profession and competency to treat cases of various severity. With this information, the counseling community can begin to know where it stands among the public and can generate education and marketing plans to expand its professional identity among consumers.

METHOD

The sample included 190 participants. Two counseling graduate assistants collected data over a period of about 6 months--at an international airport, an interstate bus/train station, and a shopping center, all of which are located in the same medium-sized southern city. On different days and at various times during the day, graduate students would invite passers-by to consider participating in a survey about mental health professionals. When individuals expressed an interest in volunteering, the counseling graduate student would immediately give them a copy of the consent form and survey. Once the consent form was signed and witnessed, subjects were asked to complete the three-part survey that included: (1) a Demographic Survey, (2) Five Case Histories and (3) the Knowledge of Mental Health Practitioners assessment instrument.

Measurements

The Demographic Survey included questions about gender, age, marital status, ethnicity, education, income, state of residence, prior therapy experience (participants indicated which mental health professional(s) they or their family had consulted).

The Case History section was designed to determine if the confidence levels in different mental health professions' ability to treat particular psychological or emotional problems systematically vary as a function of the nature and severity of the problem. Five different case histories, ranging from moderate to severe problems, were used in this instrument. Case History 1 described a 19-year-old male student who met the criteria for an adjustment disorder with academic inhibition. The person described in Case History 2 exhibited most of the severe symptoms associated with psychotic depression. An escalating marital problem (angry exchanges and periods of separation) is offered in Case History 3. The 26-year-old woman described in Case History 4 meets the criteria for the diagnosis of borderline personality disorder, and Case History 5 describes a woman with post traumatic stress disorder (PTSD). The criteria for severity of these cases was established by Wollersheim and Walsh (1993). Cases 1 and 3 would be classified as mild in comparison to case 2, 4, and 5; Case History 2 is categorized as the most severe. The five sample cases were identical to the cases used by Wollersheim and Walsh (1993) which were originally adapted from Spitzer et al. (1981).

All five case histories have been used previously as vignettes (stimulus conditions) in research studies where participants were asked, among other things, to rate their confidence in various mental health professions' ability to successfully treat various problems. While this research uses the same five vignettes that Wollersheim and Walsh (1993) used in their study, there were notable differences regarding the way participants are asked to respond to the vignettes. In the Wollersheim and Walsh (1993) study, participants were asked to rate on a 10-point Likert scale, their level of confidence in each of three mental health professionals (licensed professional counselors, clinical psychologists, and psychiatrists). In the current study, participants were asked to rank-order, rather than rate, an expanded pool of five, rather than three mental health professionals according to their level of confidence about how well each particular mental health professional could help the person described in the vignette. This alternative approach has two advantages. First, asking subjects to rank-order the professions presses them to specify whom they might actually choose. Second by adding social workers and doctoral-level licensed professional counselors to the existing list of psychiatrists, psychologists, and master's-level licensed professional counselors respondents have a more complete pool of professionals to choose from. Rank-ordering responses and choosing from an expanded pool of professionals enable the respondents to more closely approximate the realities that are associated with selecting a mental health professional.

In the introduction to the Case History section, participants were urged to carefully read the case histories and to imagine that each one described a personal friend whom they were concerned about. After reading the case history, subjects rank-ordered (a) licensed clinical psychologists, (b) master's-level licensed professional counselors, (c) doctoral-level licensed professional counselors, (d) psychiatrists and (e) social workers according to how confident they felt each particular professional could help the person described in each particular case history. Participants were required to rank all five mental health professionals on a scale from one to five with no ties in rank permitted.

The Knowledge of Mental Health Practitioners assessment formed the last section of the survey. This 14 item multiple choice test was designed to determine how much the general public knows about the professional training requirements and, to a lesser extent, scope of practice of licensed professional counselors, licensed clinical psychologists, psychiatrists, and social workers. These items were created from information contained in the licensing laws that govern each profession. For example, one question asked participants to identify the mental health professional who must have an M.D. Participants answered questions with the single best response except for two items where there was more than one correct response. For example, the question that asked which professions require the master's degree would have both social workers and licensed professional counselors as correct answers. Four questions pertained to psychiatrists; four pertained to psychologists, three to social workers and five to licensed professional counselors. The total is greater than 14 because some questions pertained to more than one mental health profession.

RESULTS

The sample contained a nearly equal number of men (51%) and women (49%). The age ranges of the sample population were broken down as follows: 32% of the sample was between the age of 18 and 25, 12% was between the age of 26 and 30, 20% between the age of 31 and 40, 19.5% was between the age of 41 and 50, 8.9% was between age 51 and 60, 5.3% of the sample was between age 61 and 70, and only 1.1% of the sample was older than age 70. It is interesting to note only 16% of the sample were above the age of 51, perhaps a reflection of the transportation settings in which the majority of the research was conducted. The participants' level of education was varied. Only 11.8% had not finished high school, 24.8% were high school graduates, 32% had some college coursework, 21.3% had a BA degree, and 10.1% had a post graduate degree.

The fact that the research was conducted in Southeast Louisiana is evidenced in the ethnic composition of the sample: Caucasians formed about 48% of the sample and African Americans about 36%. The remainder of the sample was comprised of Hispanics (3.9%), Native Americans (5.6%), one Asian (.6%) and others (6.1%). Roughly, 33% of the sample earned less than $25, 000 per year. The income range with the next highest frequency (26.8%) was between $26,000 and $35,000 per year. The income levels reported are consistent with what might be expected because of the large number of people between the ages of 18 and 25, the lowest income years. The income range of $36,000 to $ 55,000 had the next highest reported frequency (19.1%). The higher income ranges occurred less frequently: 7.1% of the sample reported income in the range of $56,000 to $ 75,000, 3.3% of the sample reported an income between $76,000 and $95,000, and 3.8% of the sample reported income in the range of $96,000 to $115,000. Finally, 6.6% of the sample reported an income greater than $115,000. While nearly 50% of the sample was from Louisiana, 30 other states were represented, some by as many as 10 people and 13 by as few as one person. The sample was consistent with expectations for research conducted in public transportation settings and in a city that attracts many tourists.

Many participants had obtained prior mental health services for themselves and/or for family members. The mental health professionals selected most frequently by subjects were social workers, reported by about 33% of the participants. Psychiatrists saw about 20%; psychologists, about 18%; master's-level licensed professional counselors, about 12%; and doctoral-level licensed professional counselors, about 7%.

Because participants were asked to rank (ordinal level of measurement) the mental health professionals, a Friedman nonparametric test was used to determine if the differences in the rankings were statistically significant. Statistically significant differences in the mean ranks were found when each of the five case studies were analyzed: Case history 1, [[Chi].sup.2] = 80.11 (n = 190, df = 4, p [is less than] .05); Case history 2, [[Chi].sup.2] = 234.90 (n = 190, df = 4, p [is less than] .05); Case history 3, [[Chi].sup.2] = 80.11 (n = 190, df = 4, p [is less than] .05); Case history 4, [[Chi].sup.2] = 234.90 (n = 190, df = 4, p [is less than] .05); and Case history 5, [[Chi].sup.2] = 105.2 (n = 190, df = 4, p [is less than] .05). Figure 1 shows a graph of the mean ranks for each mental health specialty broken down by each of the five case histories. The higher the mean rank, the higher the level of confidence. A series of Wilcoxon Matched-pair tests were used as post-hoc tests. Table 1 describes the results of the post-hoc testing completed for each case. Mental health specialties that are grouped together were not statistically significantly different from one another.

Table. Wilcoxon Matched-Pair Post Hoc Test Results

Groups                                    Case Types

           Adjustment      Psychotic       Marital
           Disorder        Depression      Problems

Highest    Ph.D. LPC       Psychiatrist    Ph.D. LPC
Rank                                       MA LPC
                                           Psychologist

Second     MA LPC          Psychologist    Psychiatrist
Highest    Psychologist    Ph.D. LPC       Social Worker
           Psychiatrist

Third      Social Worker   MA LPC
Highest

Fourth
Highest                    Social Worker

Fifth
Highest

Groups
           Borderline       Post Traumatic
           personality      Stress Disorder
           Disorder

Highest    Psychiatrist     Psychologist
Rank                        Psychiatrist
                            Ph.D. LPC

Second     Psychologist     MA LPC
Highest

Third      Ph.D. LPC        Social Worker
Highest

Fourth
Highest    MA LPC

Fifth      Social Worker
Highest

Note: Mental health specialties within groups are not statistically significantly different from one another (p [is less than] .05)

The average number of correct responses for the 14-item Knowledge of Mental Health Practitioners assessment was 6.33 with a standard deviation of 2.58. The Spearman-Brown split-half reliability estimate was .51, which is acknowledged as a possible limitation of this study. On the average, subjects tended to get more than half the questions wrong. Questions about psychiatry were correctly answered more frequently than those pertaining to the other mental health professions. The subjects, on average, knew the least about LPCs.

DISCUSSION

The purpose of this research was to explore empirically the public's confidence in mental health professionals' ability to treat clinical cases of various severity. The study sought to improve on past research by adding to the list of available mental health professionals, by using a public sample, and by having the respondents rank their preferences in order to simulate the real life choice process of selecting a mental health provider.

Many findings were consistent with expectations. For example, the mean ranks for psychiatrists were highest and substantially higher than ratings for the other mental health professionals for the psychotic depression and borderline personality disorder cases. For less severe adjustment disorder and marital problem cases, psychiatrists were ranked fourth behind doctoral-level LPCs, psychologists, and master's-level LPCs. Psychiatrists, across all cases, possess the most differentiated graph. The differentiation, paired with the results indicating that the public knew the most about psychiatry, could be interpreted as indicating that psychiatrists have a well-formed identity as compared to the other mental health professions.

Consistent with Wollersheim and Walsh's (1993) earlier findings, psychologists were consistently ranked about the same across all five case histories. Psychologists were ranked second in two cases (psychotic depression and borderline personality), third in two cases (adjustment disorder and marital problem), and a close first with PTSD. The mean level of confidence produced the flattest plot of all the professions, suggesting a consistent, yet mediocre level of confidence. Wollersheim and Walsh (1993) found similar results and remarked that the findings suggested that psychologists lacked a well-defined identity in the eyes of the public.

New findings produced by this study include the differentiation of doctoral-level and master's-level LPCs. Master's-level LPCs received means of confidence similar to those by Wollersheim and Walsh (1993). In the severe psychotic depression, borderline personality, and PTSD cases, master's-level LPCs were ranked below psychiatrists and psychologists. In the less severe adjustment disorder and marriage problem cases, they were ranked above the two other professions. However in this study, the master's-level LPCs ranked behind doctoral-level LPCs in every case. Additionally, the pattern for doctoral-level LPCs is quite similar to the psychologist's pattern with the possible exception that psychologists obtained a higher mean rank for confidence in dealing with borderline personality disorder. Even though the knowledge of LPCs was low, the public's confidence in doctoral-level LPCs was higher than their master's-level counterparts, and the public seemed to equate psychologists with the doctoral-level LPC in terms of confidence levels. Future studies can explore the perceived similarities between psychologists and doctoral-level LPCs as well as the factors that create the preference of doctoral-level LPCs over their master's-level counterparts.

Social workers were consistently ranked lowest among the four other professions and in four of the five case histories, the differences were substantial. Figure 1 depicts this difference and illustrates that the highest ranking given to social workers was for marital problems case. This unanticipated finding is further complicated by the fact that social work was the most popular choice for mental health services within the sample; 33% of the subjects had been seen by social workers or had a family member seen by a social worker. It is beyond the scope of this study to draw conclusions about the impact of experience on perceptions of mental health professionals. New studies that examine how experience with mental health professions impact opinion could shed some light on this finding.

[Figure 1 ILLUSTRATION OMITTED]

Figure 2 is based on the same data contained in Figure 1 but it presents the information in a way that allows the reader to see how the rankings on all five case histories cluster for each mental health professionals. For example, master's-level LPCs predictably received the highest rankings for marital problems and the lowest for paranoid depression. Psychiatrists' rankings covered the widest range with unsurpassed high mean rankings for treating paranoid depression and PTSD and substantially lower rankings for treating marital problems and adjustment disorders. With the exception of consistent low levels of confidence in social workers, regardless of problem type, the other findings are quite consistent with expectations.

[Figure 2 ILLUSTRATION OMITTED]

For future studies on the public's perceptions of mental health practitioners, we offer a few recommendations. By using creative techniques to attempt to get a representative sample, this study did make an improvement in the existing literature using undergraduates as a sample source. Despite this improvement, the sample size could be increased to make the findings more robust. One possible limitation of the study is that the participation rate is only estimated at around 90%. The percentage is an estimate because the methodology did not include a formal record of those who declined to respond to the survey. Additionally, a replication that utilizes a nation-wide sample might yield more information on how the public views mental health fields. Additionally, further study could examine specific ethnic groups' and socio-economic levels' confidence in the mental health disciplines to improve service to these populations (see Grossack, 1954).

Methodologically, one crucial point needs to be modified in future studies. The case study protocol for rankings listed the professions in the same order for every case. Without rotating the professions, the study could have produced a response bias in the rankings. Possible evidence of the bias might be located in the fact that social workers were both listed and ranked last in every case. However, we do want to point out that psychiatrists were listed fourth and yet they were ranked both high and low among the cases. Regardless, replication researchers are encouraged to rotate the professions to prevent the possible bias and clarify the results.

Overall, the results from this study indicate that the counseling profession still has to work to construct the identity that conveys the values and mission of the profession. Despite uncertainty within the profession, this study points to some clear counselor identity issues as seen through the eyes of our clients:

1. The public sampled knows the least about LPCs than any of the other professions. This is a knowledge-based deficit that can be remedied though public education efforts.

2. Doctoral level LPCs were preferred in every case over master's-level LPCs.

3. Overall, the public sampled was confident in LPCs' ability to treat less severe cases and less confident in their ability to treat serious psychiatric disorders.

While this study provides some groundwork for getting the public's views into the counselor identity debate, we hope that future efforts will continue to take into account the client's voice so that the profession may reach a more informed view of how it is perceived from the outside.

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Kevin A. Fall, Ph.D., is an assistant professor and chair, Department of Education and Counseling; Justin E. Levitov, Ph.D., is an associate professor, Department of Education and Counseling; Maureen Jennings and Stephanie Eberts are graduate assistants. All are with Loyola University-New Orleans, LA.

Correspondence concerning this article should be addressed to Dr. Fall, 6363 St. Charles Ave., Box 66, New Orleans, LA 70118; Email [e-mail].