Attitudes regarding interpersonal relationships with persons with mental illness and mental retardation.
Negative attitudes and a high degree of social distance towards people with disabilities has been well documented. Research has shown, however, that the degree of social rejection and social stigma varies with specific disabilities, creating a well-defined hierarchical order (Strohmer, Grand, & Purcell, 1984). In studies examining the hierarchical attitudes towards disabling conditions, mental retardation and mental illness have consistently been cited as the least socially accepted (Lyons & Hayes, 1993; Jones, Gottfried, & Owens, 1965; Karnilowicz, Sparrow, & Shinkfield, 1994).
Negative social responses to persons with mental retardation and mental illness have persisted across generations despite improved care, legislative support, and a more sophisticated medical understanding of the causes and origins of these disabilities. During a time of heightened social awareness, social tolerance in the sixties and seventies began to slowly evolve. Social activists reacted to the "dehumanizing conditions and the absence of individual dignity" evident in institutions serving persons with disabilities, and called for institutional reform and accountability (Scheerenberger, 1987, p. 221). The Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963 furthered the rights of persons with mental retardation and mental illness, resulting in the institutional release of thousands of individuals (Scheerenberger, 1987). With the passage of five major legislative titles under the American with Disabilities Act, growing social awareness and continued efforts towards social progress continued through the 1990's (Rubin & Roessler, 1995). More recently, public service groups have attempted to increase public acceptance of disabilities such as mental illness through educational media campaigns (Martin, Pescosolido, & Tuch, 2000). By building awareness, the hope has been to increase social acceptance and decrease prejudice towards persons with differing abilities.
Social Rejection and Social Distance
Unfortunately, efforts to reduce negative stereotypes toward disabilities do not appear to have been substantially successful. Link and Phelan (1999) examined national survey data collected in 1996 to assess public conceptions of mental illness. Their findings support both a greater public knowledge of mental illness and an understanding of causal etiology. However, cultural misconceptions attached to mental illness also appear to exist, confounding an already meager understanding of accompanying characteristics and behaviors. Data showed that a significant attribution for increased violence in social interactions was attached to all of the mental disorders listed in the study. In addition, the more violent a mental disorder was perceived, the greater social distance desired by the respondents.
Similarly, a high degree of social rejection of persons with mental illness was also found in a study that compared reactions to the behaviors of individuals labeled as mentally ill and those labeled as physically ill (Socall & Holtgraves, 1992). Findings confirmed more willingness to interact with an individual labeled as physically ill than with a similar individual labeled as mentally ill. Desired social distance also increased with severity of symptoms. Negative social stereotypes about mental illness over-rode observed behaviors, leading to an increase in social distance. Public attitudes toward persons with mental illness were also compared using a public survey completed in the 1950's and the Mental Health Module of the 1996 General Social Survey (Phelan, Link, Stueve, & Pescosolido, 2000). Findings suggest that although the public has developed a realization that mental illness is something that can happen to anyone, the perception of persons with mental illness as violent and dangerous actually increased more than twofold.
Likewise, studies examining mental retardation have also illustrated a significantly negative social attitude. Mental retardation, described as "the most socially invisible of all people with disabilities" (Smith & Anton, 1997, p. 398) creates similar negative social attitudes. Measuring the social attitudes of high school students, Kamilowicz and associates (1994) compared attitudes about interacting with nondisabled peers, physically disabled peers, and mentally disabled peers and found students less willing to interact with persons with mental disabilities. In comparing twelve disabilities, Lyons and Hayes (1993) found that occupational therapy students reported a hierarchical preference citing mental illness and mental retardation as least preferred disabilities. Corrigan, River, Lundin and others (2000) also found "differential discrimination" among disabilities when examining social attributions towards persons with mental health disabilities. Persons with mental retardation were rated as least stable while persons with specific mental illnesses were rated as least controllable. The implications of these negative social attitudes toward persons with mental retardation and mental illness are significant. These social misperceptions and stereotypes of persons with mental disorders as instable, unpredictable and dangerous appear to have serious consequences in the willingness of the nondisabled to interact and pursue interpersonal relationships (Lyons & Hayes, 1993).
Friendships and interpersonal connections are important in all people's lives. According to Lutfiyya (1991), friendship is a reciprocal endeavor which includes a sharing of resources (e.g., time, emotional support, material objects). Friendships are intrinsically motivated and derive from a mutual decision for an alliance (Green, Schleien, Mactavish, & Benepe, 1995). Friendship development depends on the opportunity to interact with others, appropriate social and interpersonal skills, and the ability to initiate and sustain a relationship.
Early research examining interactional difficulties between persons with and without disabilities has looked at issues of discomfort and unease identified as "interaction strain" (Davis, 1961; Evans, 1976). Others noted the "novelty" of the interactional situation and self-consciousness over appropriate behavior during the interactions may also contribute to the problem (Fichten, 1986; Wright, 1983). According to Fichten, Robillard, Judd, and Amsel (1989), persons without disabilities perceive those with disabilities to be different across several social dimensions (e.g., to be more socially anxious, uneasy about dating, less likely to date). In addition, attitudes regarding persons with specific disabilities such as mental retardation and mental illness appear to be particularly harsh (Corrigan, Green, Lundin, Kubiak, & Penn, 2001; Link & Phelan, 1999; Lyons & Hayes, 1993).
The impact of these negative attitudes have significant consequences for both the social and vocational lives of persons with disabilities such as mental illness and/or mental retardation. Link and Phelan (1999) note that cultural views about mental illness typically revolve around the notion that persons with this disability are more likely to be violent and possess more undesirable characteristics. While persons with mental retardation are frequently viewed in a more positive light overall and with less fear than those with mental illness, they are also less often perceived as potential friends. In a study focused on interactions between persons with severe mental retardation and their nondisabled peers in an integrated workplace, Rusch, Wilson, Hughes, and Heal (1995) found that although persons with mental retardation were accepted within the workplace, few were befriended outside of the work setting. This concurs with an earlier study that found interactions between co-workers in supported employment settings rarely transcend the work environment (Rusch, Hughes, Johnson, & Minch, 1991). Perhaps more critical, Ferguson, McDonnell, and Drew (1993) found that workers without mental retardation initiated interactions with nondisabled co-workers three times more often than with co-workers with mental retardation. The researchers report that attitudes and behaviors by the nondisabled workers suggested that their views toward their disabled peers were not necessarily derogatory but also were not those of equals. In regards to mental illness, Martin, Pescosolido, and Tuch (2000) found one-third to one-half of their participants unwilling to have interactions with persons identified as depressed or schizophrenic. They found that approximately 20% reported not wanting "social involvement with people with 'troubles'." (p. 219).
On a more positive note, there has been the suggestion that increased contact and greater awareness of disability issues have begun to improve societal attitudes about disabilities. Link and Phelan (1999) suggest that although attitudes about mental illness remain negative, understanding about the underlying causes have become more reasonable. In a meta-analysis of 35 studies, Kolodziej and Johnson (1996) found that increased contact between persons with mental illness and students and mental health employees improved attitudes. The more frequent the contact, the less authoritative and restrictive were the attitudes of the nondisabled. Corrigan and associates (2001) also reported more public familiarity with mental illness. In addition, Green and colleagues (1995) note that positive interactions occurring early in the relationship between persons with and without disabilities tend to "minimize the perception of differences, and result in an optimistic attitude toward friendship development" (p. 96).
Although recent literature reports a tendency for more positive views in general about disability, limited research has examined the impact of knowledge about disability on levels of social distance. Particularly absent is research focused specifically on attitudes regarding friendship and more intimate relationships with persons with mental illness and mental retardation. With increased awareness of disability issues, we became interested in whether greater knowledge and contact with persons with disabilities has actually impacted perceptions about interpersonal relationships with persons with mental illness and mental retardation. Therefore, this study examined the following questions:
1. Are there differences between attitudes of a nondisabled group regarding friendship and marriage with persons with mental illness and mental retardation compared to other disability populations?
2. Does gender, education on disability issues, and current friendships with persons with disabilities impact perceived knowledge of and desired social distance from persons with mental illness by a nondisabled group?
3. Does gender, education on disability issues, and current friendships with persons with disabilities impact perceived knowledge of and desired social distance from persons with mental retardation by a nondisabled group?
This study included 218 undergraduate students from a mid-western university. All participants were students enrolled in at least one counseling psychology undergraduate class. They signed up to complete the study through a departmental volunteer pool and were given one hour of research credit in their undergraduate course for their involvement.
Volunteers were given a brief demographic sheet and a questionnaire regarding knowledge about 13 disability populations. In addition, they were asked to respond to a modified Social Distance Scale (Bogardus, 1932).
Demographic Sheet. Participants were asked questions pertaining to gender, age, ethnicity, educational level, and current friendships with anyone with a disability. In addition, they reported the number of courses or workshops they had taken part in that focused on disability issues. They were also asked whether they knew about ADA and if they said yes, what they saw as the overriding purpose of the law.
Knowledge Scale. Participants completed a one page form (created for this study) where they ranked 13 disabilities on their knowledge about the disabilities (i.e., 1 = know the most, 13 = know the least). In addition, they were asked to rate each disability on a scale of 1 to 4 (with 1 = great knowledge and 4 = no knowledge) concerning their perceived knowledge of each of the 13 disorders.
Social Distance Scale. The Social Distance Scale (SDS) based on a model by Bogardus (1932) was utilized in the current study. Social Distance scales have been widely used in attitude studies regarding disability (e.g., Corrigan et al., 2001; Eisenman, R., 1986; Eisenman, R., 1972; Jones, Gottffried, & Owens, 1986; Olkin & Howson, 1994; Triandis & Triandis, 1965) and are reported to be a valid and reliable measure (Corrigan et al., 2001). Although the reliability was not reported originally by Bogardus, subsequent studies have reported split-half reliability in the .83-.95 range (Kleg & Yamamoto, 1998). Modifications were made to the original scale to make the interaction specific to disability populations. Participants were asked to rank level of relationship in which they would be comfortable when interacting with persons with 13 different disability/chronic health conditions. There were seven levels of interaction which ranged from speaking to marrying a person with the designated disability. Both visible and invisible disabilities were included. In the current study, Cronbach's alpha was .95.
Characteristics of the Sample
The sample consisted of 218 participants. This included 78 males (35.9%) and 139 females (64.1%). One participant did not indicate gender on the demographic sheet. The mean age was 21.4 with an age range of 18 to 35. Twenty-four participants (11%) reported being African-American, 187 (85.8%) as Caucasian, and seven participants (3.2%) as Asian-American, Hispanic or other. Approximately 36% of the sample reported currently having a friend with a disability while nearly 65% stated that they had no friends with disabilities at the current time. Fifty-nine individuals (27.1%) indicated that they had taken coursework in disability issues or had knowledge about ADA compared to 159 individuals (72.9%) with no courses or ADA knowledge.
Participants reported having less knowledge about mental retardation than mental illness (See Table 1). More than 65% reported having either great or some knowledge about mental illness. In contrast, only 11% of the participants reported great knowledge of mental retardation.
Friendship and Disability
The first question pertained to attitudes about being friends with persons with mental illness and mental retardation as compared to other disability populations. When examining views regarding being "regular friends," persons without disabilities identified those with mental illness and mental retardation as the least desirable for friendship. See Table 2 for participants' rankings of attitudes about friendship with the 13 identified disabling conditions.
Persons with Mental Illness
A 2x2x2 MANOVA was conducted to examine the main effects of gender, workshop history (i.e., whether or not participants have taken a workshop on disability issues), and friendship (i.e, whether or not participants have a friend with any kind of disability) on the dependant variables: knowledge of mental illness and desired social distance from persons with mental illness. The multivariate effect was significant (Wilks' Lambda = .096, F = 928.77, p <. 001). Therefore, univariate tests were examined.
The univariate F test for gender and knowledge of mental illness was significant (F = 10.05, p < .01), thus indicating gender differences in knowledge of mental illness. The mean score on knowledge of mental illness for women was 2.02 (SD = .86) and for men was 2.46 (SD = .77). Lower scores indicate greater knowledge. Thus, women reported more knowledge of mental illness than did men. There was a modest effect of gender on social distance from persons with mental illness (F = 5.38, p < .05). The mean score on desired social distance from persons with mental illness was 4.50 (SD = 1.82) for women and 4.08 (SD = 1.75) for men. Higher scores indicate less desire for social distance. Thus, women reported less need for social distance from persons with mental illness than did men. The univariate F tests for workshop history and for friendship were not significant. This indicates that no differences were found in knowledge of mental illness or desired social distance from persons with mental illness on the basis of workshop history or friendship with a person with a disability.
Persons with Mental Retardation
A 2x2x2 MANOVA was conducted to examine the main effects of gender, workshop history (i.e., whether or not participants have taken a workshop on disability issues), and friendship (i.e., whether or not participants have a friend with any kind of disability) on the dependant variables: knowledge of mental retardation and desired social distance from persons with mental retardation. The multivariate effect was significant (Wilks' Lambda = .088, F = 1028.29, p < .001). Thus, the univariate tests were examined.
The univariate F test for gender was not significant. No gender differences were found in knowledge of mental retardation or desired social distance from persons with mental retardation. The univariate F test for workshop history and knowledge of mental retardation was significant. For participants who had attended a workshop on disability issues, the mean score on knowledge of mental retardation was 2.11 (SD = .66). For participants who did not attend a workshop on disabilities issues, the mean score on knowledge of mental retardation was 2.54 (SD = .81). Lower scores indicate greater knowledge. Thus, those who attended a workshop on disability issues reported greater knowledge of mental retardation. The univariate F test for workshop history and social distance from persons with mental retardation was not significant. The F test for friendships was also nonsignificant.
This examination of knowledge and social distance provides several areas for consideration. Although over 60% of the participants in this study indicated a willingness to be friends with persons with differing disabling conditions, mental retardation and mental illness were the lowest rated disability populations. While over 83% of the participants noted they would be friends with persons with the other 11 disability populations, only 71.6% stated they would be friends with a person with mental illness. In addition, only 68.8% reported a willingness to be friends with persons with mental retardation. Not surprisingly, as the level of the relationship became more intimate, there was less willingness to interact. Only 12.8% of the participants would marry a person with mental illness while only 4.1% of the participants indicated they would marry a person with mental retardation.
These numbers are of particular concern because the sample population consisted primarily of young adults who are the age group most likely planning to marry. The reluctance to even become friends with persons with mental illness and mental retardation is therefore critical. Persons with these disabilities are leaving the school environment during young adulthood where friendship building is typically conducted within the community or work arena. It is discouraging that so many young adults without disabilities would not consider developing friendships with people with mental illness and/or mental retardation. It is also startling that although the vast majority of persons noted they would be friends with persons with disabilities in general, only about 36% of the sample indicated currently have a friend with a disability.
Counselors need to be aware of the attitudinal barriers clients with mental illness and mental retardation face when developing friendships. Consistent with prior research (Corrigan et al., 2001; Karnilowicz et al., 1994), this study also found persons with mental disabilities to be perceived as the least desirable for interactions. Consequently, counselors can be instrumental in assisting clients with mental illness or mental retardation in friendship development and building. The opportunity to interact with others has been reported as a key ingredient in friendship development. Chronologically age appropriate social skills are also critical in the development and maintenance of friendships (Siperstein, Leffert, & Widaman, 1996). Due to the reciprocal nature of friendships, some persons with mental illness and/or mental retardation may also need specific training in identifying and meeting interpersonal obligations (Doll, 1996). Counselors can work with clients with mental disabilities to generate appropriate social skills across settings and situations. Although social skill training can be completed through role playing and education, it is more likely to be successful if the skills are taught within a context of real life and in natural settings.
Although prior research has reported mixed findings when examining gender and attitudes about disability, gender was found in this study to be of importance when considering interpersonal relationships with persons with mental illness. Women reported having greater knowledge about mental illness and also more comfort in perceived interactions that men. In contrast, no gender differences were found on knowledge of mental retardation or social interaction comfort. Assumptions, though, about male or female attitudes regarding disability groups should not be made. Further analysis indicated that few participants actually felt they knew a lot about mental retardation. While persons indicated greater perceived knowledge about mental illness, the accuracy of their knowledge level is unknown. Consequently, it does bring up a critical issue regarding the need for greater education particularly about those disabilities most at risk for stigma, and a more intense examination of the type of information provided (Kolodziej & Johnson, 1996). Education that emphasizes the strengths of persons with mental illness and mental retardation may be essential. This issue of content was further highlighted by Eayrs and Ellis (1990) when they examined the conflicting messages organizations present when they attempt to raise awareness of a disorder and raise funds simultaneously. Raising sympathy for a disadvantaged group frequently does little to promote positive interactions, and marketing strategies may actually reinforce negative stereotypes (Corrigan et al., 2001). Counselors and members of the identified groups may need to advocate on behalf of persons with disabilities to change stereotypical portrayals often presented by fund raising organizations. Future research on the characteristics of educational programs that actually promote positive attitude change is critical.
Some studies concerning attitudes, social distance, and mental illness and/or mental retardation reveal numerous characteristics of appropriate education and contact strategies. Lyons and Hayes (1993, p. 546) suggest that strategies to improve attitudes toward persons with mental illness by professionals include "guided contact" over a period of time for students in training. In addition, training should include both work in the field and interactions in non-clinical settings with persons with mental illness and their families. Kolodziej and Johnson (1996) also stress the importance of contact that is voluntary for the person without a disability and also takes into consideration the characteristics of the person with mental illness. It appears that structured and planned contact is essential.
Do disability workshops adequately address issues of mental illness? There was no effect for workshop training on desired social distance for persons with either disorder. Workshops may provide information about disabilities but may not be adequate to promote any attitudinal shifts. Unfortunately, while participants felt they actually knew more about mental illness, media biases and such may be distorting the reality of the illness (Martin et al., 2000). Counselors and educators may need to examine their representation of different disability groups during workshop trainings.
Surprisingly, current friendship with persons with disabilities did not appear to impact desired social distance. Although one might expect those who have had more contact with disability issues and/or persons with disabilities to express more comfort in interactions, this was not the case in this study. Since participants were not asked about the type of disability of their friends, it is not know whether results would have differed if we had examined participants who listed persons with mental disabilities as current friends. Perhaps the particular stigma attached to these disorders do not allow attitudes to transverse various disability types.
Overall this study appears to support prior research regarding interaction barriers for persons with mental illness and mental retardation. Despite the wide efforts to promote more positive perceptions of disability, and these two disabling conditions in particular, large numbers of persons still report them as undesirable for friendship. In addition, workshop education and current friendships appear to have little influence on issues of social distance. Caution must be taken when examining the results of this study. The sample was a fairly homogeneous population drawn from a midwestern university. Although there are a number of students with disabilities on the campus, diversity in general is limited. Results may have differed if the participants were more routinely exposed to persons that differ from them. This study was also limited in the diversity of participants. Less than 15% reported being minority members. Furthermore, all participants were undergraduate students who had volunteered to participate. These results may not be reflective of the general population.
In addition, this study utilized self-report measures. Participants may have responded in a manner not consistent with their behavior. Participants also indicated their perceived level of knowledge about each of the disabling conditions. Actual knowledge may have been either under-estimated or over-estimated.
Despite the limitations, this study does highlight significant interaction barriers confronting persons with mental disabilities. Counselors can provide valuable assistance in addressing these problems in a number of ways. First, counselors need to examine their own biases regarding persons with mental illness and mental retardation. As Ferguson and associates (1993) note, persons with mental retardation may not be viewed negatively by the nondisabled but they are frequently not perceived as equals. Counselors are not immune to these stereotypes and need to examine any views they harbor about these disorders that might hinder them in assisting clients in a broad range of interpersonal relationships. Secondly, counselors may need to help clients with disabilities deal with public attitudes. Clients may experience lowered self-esteem and a sense of isolation due to difficulty in making friends. In the same vein, counselors can help clients develop and incorporate appropriate social skills in their interactions. Counselors should also recognize that the interaction problem often does not lie with the person with the disability. Finally, counselors may need to become aware of actual variables that influence attitude change. Through this knowledge, counselors can plan and/or coordinate activities more likely to improve interactions between those with and without disabilities. Counselors can help promote more positive attitudes about disability with their nondisabled clients as well as become advocates for disability concerns. They should be proactive in promoting positive relationships between all people regardless of differences.
Table 1. Levels of Perceived Knowledge reported by Participants Knowledge Level Mental Retardation * Mental Illness * Great Knowledge 23 (10.9%) 48 (22.7%) Some Knowledge 92 (43.6%) 91 (43.1%) Little Knowledge 78 (37.0%) 59 (28.0%) No Knowledge 18 (8.5%) 13 (6.2%) * Missing data for seven participants Table 2. Percentage of Participants who would be a Friend and / or Marriage Partner Disability Type % who would be a friend % who would marry Arthritis 98.6% 86.2% Cancer 97.2% 50.9% Diabetes 98.6% 82.1% Hearing Impaired 93.6% 54.1% Heart Condition 97.7% 63.3% Learning Disability 93.6% 59.2% Mental Illness 71.6% 12.8% Mental Retardation 68.8% 4.1% Multiple Sclerosis 85.8% 25.7% Muscular Dystrophy 85.4% 21.1% Paraplegia 88.5% 25.7% Quadriplegia 83.9% 19.3% Visual Impairment 93.6% 45.0%
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Dr. Phyllis A. Gordon, Professor Of Psychology--Counseling Department of Counseling Psychology and Guidance Services, TC 622, Ball State University, Munche IN 47306. Email: email@example.com
Phyllis A. Gordon
Ball State University
Jennifer Chiriboga Tantillo
Ball State University
Ball State University
Ball State University
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|Publication:||The Journal of Rehabilitation|
|Date:||Jan 1, 2004|
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