Community Responses to the Mentally Ill

Attitudes
Public opinion surveys since the 1950s have charted attitudes about the mentally ill. Dislike and
fear of the mentally ill remain high in these surveys. Negative attitudes are particularly
pronounced among the poorly educated and among elderly people. Men consistently report more
negative attitudes toward the mentally ill than do women. The core concerns about mentally ill
people revolve around their presumed unpredictability and dangerousness. These concerns have
some basis in reality, as patients released from state psychiatric hospitals evidence comparatively
high arrest rates. However, most crimes committed by released patients are property crimes that
do not involve violence. Unfortunately, the mass media typically emphasize cases in which
people with a history of emotional problems commit violent crimes, thus exacerbating the
problem of public misperception.
Intensely negative attitudes about the mentally ill sometimes appear to be part of a larger cluster
of beliefs, attitudes, and values characterized by an absence of sympathy for people who need
help, a deep-seated distrust of people and institutions who are different, and a rigid outlook on
what is right and wrong. Rational arguments to change their views cannot easily sway people
with this orientation. Fortunately, however, most people have much less intense negative feelings
about the mentally ill. There is good reason to believe that experience and increased knowledge
of kinds of mental illness and treatment can modify these feelings. Visits to a psychotherapist, for
example, appear much less stigmatized in public opinions than hospitalization for a mental
illness. Private hospitalization seems less stigmatizing than public hospitalization. The
perception that drug therapies are evidence of greater disorder than talk therapies provokes more
fear and distrust of these patients. For a similar reason, treatment by a psychiatrist involves more
negative attitudes than consultation with a psychologist, social worker, or member of the clergy.
Survey data suggest that contact with mentally ill people can influence attitudes of community
members. In general, survey respondents who report knowing someone with a history of mental
illness are less negative than people who report no personal contact. It is difficult, however, to
sort out cause and effect here, because negative attitudes might relate to failure to report the
mental illness of a close relative. In addition, family studies and studies of the reintegration of
former patients into their old work roles show that contact with former coworkers and associates
promotes positive attitudes about the mentally ill. Seeing a former patient perform adequately in
a normal role is particularly important in this regard. Self-disclosure by the former patient about
what having a mental illness and being hospitalized was like also helps promote normalization
and acceptance by reducing the aura of mystery that otherwise surrounds the illness.
Much less is known about how to change negative attitudes about mental illness in general as
opposed to attitudes about particular individuals known to have a history of mental illness,
although that is the focus of much empirical research and theorizing by sociologists involved in
this area of investigation. Studies of the mass media show that the stereotyped depictions of
former patients that commonly appear on television and in movies reinforce negative public
perceptions about the mentally ill. Whether sympathetic treatments of mentally ill people in the
mass media might change these negative attitudes or whether informational campaigns making
use of the mass media could increase public knowledge about mental illness is less understood.
This last issue attracts considerable interest because of the launch of several large mass media
campaigns designed to increase public awareness, recognition, and treatment of mental illness.
The National Institute of Mental Health developed one such campaign to increase knowledge
about anxiety and depression and to encourage increased voluntary help seeking for these

disorders. Unfortunately, this campaign did not include an evaluation, so the kinds of message
strategies and information channels that led most effectively to attitude and behavior changes
among persons with these disorders can only be inferred. Gauging from the experiences of health
educators in conducting campaigns aimed at other public health problems, information of this
sort is vitally important to successful campaign design and implementation.
A more recent related campaign instituted an annual national depression awareness day in which
mass media around the country mobilized to encourage possibly depressed people to seek
treatment. Local screening sites and a toll-free number facilitated screening and encouraged
people who screen positive to seek treatment. Evaluations show that this growing campaign
succeeded in bringing tens of thousands of people into treatment. Comparable programs were
established to create annual national anxiety disorder, eating disorder, and substance abuse
screening days. Refining the messages and referral strategies of these campaigns to increase their
reach and effectiveness needs interdisciplinary research that takes into consideration the
importance of social and personal barriers.
Community Reactions to Sheltered Care Homes
Negative attitudes about the mentally ill are important for a number of reasons, including the fact
that they inhibit help seeking for personal problems and interfere with the recovery and
reintegration of mentally ill people into normal social roles. Another way in which these negative
attitudes interfere with the treatment of mentally ill people involves attempts to establish group
homes for the mentally ill. Sociologists have done a great deal of research on collective action.
Community opposition to group homes is one of the mobilization activities studied by those
working in this tradition. This research shows clearly that middle-class neighborhoods are much
more resistant to having group homes in their midst than are working-class neighborhoods. This
greater resistance is traceable to effective mobilization efforts. In particular, efforts to meet and
organize local opposition come off much more quickly in middle-class neighborhoods in which
selection of a person or a committee to act on the neighborhood's behalf and multipronged
political actions are more likely to occur.
Attitudes also play an important role in the success of group homes in fostering readjustment
among deinstitutionalized patients. Ethnographic research shows clearly that patients are aware
of the accepting or rejecting attitude climates in their neighborhoods and that this influences their
social functioning. The ease with which the residents of these homes adjust to life in the
community depends largely on community acceptance. The conflict that can attend the creation
of the home does not make a good foundation on which to build such acceptance. In general,
public opinion surveys show that contact with former patients who are strangers exacerbates
whatever fears and uncertainties community residents already have, particularly in cases in
which conflict previously arose about the establishment of the group home.
Most sociological studies of community opposition to group homes neglect these issues and
generally concentrate on structural determinants of neighborhood mobilization and on strategies
available to agencies for diffusing this opposition. Research is urgently needed on what happens
after the home opens and the residents must live in the neighborhood. There is evidence that
contact with a former mental patient known before hospitalization can foster positive attitude
changes, especially when the former patient performs adequately in normal roles. One future
challenge is the creation of structured situations that facilitate contact between residents of
sheltered care homes and their neighbors in such a way that these kinds of positive attitude
changes can occur.

ORGANIZATION OF MENTAL HEALTH SERVICES

Research on Interorganizational Coordination
Research on complex organizations is one of the liveliest areas in sociology today as a result of
the enormous changes in the delivery and financing of health care services in the 1990s. Indeed,
the mental health care delivery system is a favorite example used by social theorists to test new
ideas about interorganizational linkage, because it provides unique opportunities to study a
decentralized system consisting of many overlapping organizations with complex coordinating
functions.
One focus of this research is the continuing diminution of state mental hospitals and the impact
of this downsizing on general hospitals and community-based programs. Although there is a
general perception that most of the reductions in state mental hospital systems throughout the
country occurred in the 1950s and 1960s, as much as a 50 percent decrease in the number of
inpatients occurred in many state mental health systems during the 1980s. The result is an
increased burden on general hospitals and a revolving-door policy whereby patients receive
treatment during periods of crisis and are largely ignored between admissions.
Case studies of community responses to these changes document enormous coordination
problems and inconsistencies in organizational rationalities. Historical analyses show that these
problems result from the accumulation over many years of decisions that lack any overall plan or
purpose. The challenge for researchers is to synthesize these case studies to discover mechanisms
that facilitate rationality in the relations among community organizations. Such work is currently
the subject of intense interest among organizational sociologists.
A related series of studies attempts to trace the influence of state and national policy initiatives
on community-based organizations and systems. Studies exist on how considerations concerning
the future actions of state and national funding agencies affect strategic decision making in local
organizations. The studies show that inability of state and national initiatives to develop
community-based programs leads to local processes of adaptation that the policy makers who
developed the programs did not intend. Current research is moving in the direction of
comparative studies aimed at isolating characteristics of particular community systems that
determine the directions of local responses.
There is also a great deal of interest in designing and evaluating organizational innovations that
might improve the quality of care for the chronically mentally ill, particularly for that segment of
patients unable to afford private care. Capitation programs, managed care programs, and
programs that mainstream the mentally ill into existing health maintenance organizations
(HMOs) created exclusively for persons with chronic mental illness are among the organizational
innovations that are currently under discussion. Notions of treatment success must broaden for
this population to include fundamental quality-of-life issues, such as adequacy of housing,
nutrition, employment, social integration, and other issues of central concern to sociologists.
As noted earlier in the chapter, new models are evolving to integrate child and adolescent mental
health clinics into schools. Interdisciplinary collaborations are also developing between social
welfare and mental health professionals to provide mental health treatment in coordination with
welfare reform. Collaborations between criminal justice and mental health workers are also
expanding. Barriers to these different kinds of collaboration include competition for funds and
inconsistent institutional demands. Organizational sociologists study all of these
interorganizational relationships in the hope of pinpointing structural changes that can reduce
barriers to collaboration.

An area of interorganizational coordination that is the subject of particularly intense debate

involves coordinated versus integrated public treatment of patients with dual diagnoses of mental
and substance use disorders. The treatment literature is quite clear in showing that patients with
serious mental disorders and co-occurring substance use disorders receive much more successful
and cost-effective care when provided with integrated treatment of both disorders by crosstrained professionals than with separate treatment of the two types of disorders by two separate
treatment providers. This is true even with coordination of the separate treatments. However,
legislatively mandated prohibitions on blending state block grant funds for mental disorders and
substance use disorders make it extremely difficult to sustain integrated treatment programs.
Substance abuse treatment professionals also actively fought against integrated treatment based
on a concern that integration would substantially reduce the funds available for substance abuse
treatment. The basis of this concern is the fact that block grants account for the majority of
public substance abuse treatment funds in many states. New incentives to integrate services for
patients with dual diagnoses are currently in development by the Substance Abuse and Mental
Health Services Administration in an effort to resolve this controversy in a way that protects
funds for substance treatment and increases access to integrated treatment.
Organizational Factors in Service Delivery
Another kind of organizational research extends the work on job stress by studying the influence
of organizational structure on the health, well-being, and productivity of its members. Some of
this work studies the structural components of mental health care organizations that affect staff
satisfaction with their work. A few studies also examined the impact of organizational structure
on patient outcomes. All of this work, as of 2003, is naturalistic rather than experimental and
comparative rather than based on case studies of individual treatment settings.
Findings include the fact that staff satisfaction and productivity are positively associated with
decision latitude. Patient functioning in long-term mental hospitals is also positively associated
with the decision latitude of lower-level staff. Other correlates of good patient functioning
include high staff job satisfaction and high staff participation in treatment decisions. Patient
functioning in acute-care inpatient settings is positively associated with an active management
style. Patient functioning in community-based shelter care homes is likely to be better when the
homes are small, have flexible rules, and require patients to take some responsibility for the
activities of daily living.
As these results suggest, there is, as yet, no overarching theoretical framework that integrates the
specific findings into a coherent model of organizational influence on staff and patient
functioning. Job redesign experiments in industrial settings will facilitate integrative work of this
type. Similar experiments in treatment meetings are much less common, although innovative
experiments are now underway to change the structures of community-based shelter care homes
in an effort to reduce the problems of staff burnout and turnover. The success of organizational
redesign efforts likely will determine whether similar experiments are carried out in a wider
range of treatment settings.
Evaluation of Community Mental Health Services
The development and maintenance of an effective community-based system require a cyclical
process of service planning, implementation, evaluation, and feedback. The first step in this
process is usually a needs assessment that identifies patterns of unmet need for treatment in the
community and establishes priorities for the creation of services to address these problems. Such

an assessment is vitally important to organizational success by monitoring demand for services

and pinpointing needs not recognized by community residents.
The most direct way to conduct such an assessment is by means of a large-scale community
survey. However, such surveys are expensive, and most local service organizations are unable to
afford them. There are a number of innovative approaches devised to obtain more indirect
information about need at a lower cost. These techniques include systematic interviews with key
informants, the establishment of citizen advisory councils, the use of national statistics on need
profiles in conjunction with small-area social indicators on community demographics, and
extrapolation from data on demand for services to estimates about need for services.
After the development of programs, research can also be important in evaluating effectiveness
and targeting areas that need to be changed. Program effectiveness relies on at least two levels of
research. The first focuses on success in attracting participants to the program; the second
focuses on success in helping people with their problems. Behavioral scientists have been more
active in the first research area than in the second area.
Research on success in attracting program participants emphasizes acceptability, accessibility,
and awareness. Acceptability refers to how willing community residents are to use the new
service. Accessibility involves how easy the program is to reach. Time, distance, transportation,
and financial barriers are all important to consider here. Awareness relates to community
knowledge that the service exists and that it is appropriate for particular needs. To develop
programs that are sensitive to these issues requires an understanding of local culture.
Sociological research using ethnographic research or other qualitative strategies can increase the
sensitivity of program staff to local norms and customs.
Research that evaluates the effectiveness of programs is much less common for several reasons:
the substantial costs of implementing a carefully controlled study of treatment effectiveness, the
high level of methodological sophistication required to carry out such an investigation, and the
potential threat to clinicians and program administrators of openly studying the therapeutic value
of their services. Although sociologists and other behavioral scientists have the expertise to do
such work, this remains an underdeveloped area of investigation.
Social Context of Professional Activity
The medical profession is undergoing enormous changes, engendered by such things as
diagnosis-related groups (DRGs) and other new payment arrangements, the shifting of care from
inpatient to ambulatory settings, the diversification of the medical care industry, the increasingly
overt competition among providers, the growing importance of third-party payers, the use of
evidence-based guidelines to control quality of care in ways that many professionals see as
constraining their autonomy, and the growth of demand management programs that empower
patients to renegotiate doctorpatient relationships. Those changes are part of broader societal
forces that include the aging of the population and cohort shifts that have led to massive
expansion in the plant facilities of the medical care industry and a marked increase in the number
of physicians in the marketplace.
Sociologists are keenly interested in the implications of these trends for the future of medicine.
One perspective holds that physician domination of the health care system is so firmly
established that it cannot be shaken by the changes in social context that are taking place. The
legal subordination of nurses, pharmacists, and other medical care professionals to the physician
is critical in this regard, as are the exclusive licensing powers granted to physicians as
gatekeepers of the medical care system. An opposing view, however, is that the medical

profession is in a period of declining power as a result of the resurgence of consumerism in

medicine. The greater number of medical patients who experience chronic rather than acute
conditions leads to the creation of interest groups. These groups consist of lay people who
acquire considerable technical knowledge about their own afflictions and tend to challenge their
providers. The technical diversification of medical procedures and the increasingly important
contributions to health care by technician-specialists who are not physicians also play a part.
With changes in the organization of professional care, new systems of ownership and
management promote competition among physicians, which inevitably brings with it increased
consumer control. Finally, the more dominant position of large insurers consolidates the
bargaining position of consumers in a novel way. These views are particularly relevant to
psychiatrists, because the existence of auxiliary mental health specialists, such as clinical
psychologists and psychiatric social workers, has no counterpart among other medical
specialties.
Another perspective on the changing nature of medical practice involves the proletarianization of
medical work. More and more physicians work as salaried employees in large, bureaucratically
managed organizations. As those organizations institute managerial styles orchestrated by the
graduates of business schools rather than of medical schools, changes in procedures for
professional control invariably will occur. Formal review procedures now apply to a wider range
of professional behaviors. Within particular institutions, mechanisms are in development to
monitor and to control the technical decisions of clinicians. All of these trends will result in
increasing external control of the domain of professional practice.
The future shape of psychiatric practice is difficult to forecast in light of these many different
forces. Sociologists who specialize in this area of research have conflicting notions, although
they all share a concern that the likely changes may adversely affect the quality of care provided
to patients with emotional problems. Carrying out programmatic sociological research that
monitors these changes and provides clear evidence regarding the effects on quality of care is
important. Despite disagreements about specifics of likely changes, it is agreed that primary care
doctors rather than psychiatrists treat more and more patients with mental health problems. This
shift coincides with a trend away from psychotherapy to pharmacotherapy as the dominant
treatment for mental disorders. The development of psychopharmacological agents that are much
easier to administer than earlier medications and the cost-cutting pressures imposed by managed
care systems drive this trend. Another important trend is to deliver combined pharmacotherapy
and psychotherapy more and more by a team made up of a primary care doctor and a
nonpsychiatrist mental health professional than by a psychiatrist. All of these changes point to
the likelihood that psychiatry will, in the future, become more similar to other medical specialties
in focusing largely on complicated cases that primary care doctors cannot manage and in
working closely in a consultative role with primary care doctors to provide expert advice
regarding the management of more routine cases. The specific decision rules for sorting cases
between general and specialty care, however, remain unclear, as does the quality of care that
patients with mental disorders who are treated in the primary care system will receive.
SUGGESTED CROSS-REFERENCES
Other discussions of sociocultural influences on psychiatry may be found in Section 4.1
(anthropology and cultural psychiatry), Section 4.3 (sociobiology and psychiatry), and Section
4.4 (sociopolitical aspects of psychiatry). Social influences on the onset and course of mental
disorders are discussed in Section 5.1 (epidemiology), as well as in the epidemiology sections
dealing with schizophrenia (Sections 12.3 and 12.4), mood disorders (Section 13.2), anxiety

disorders (Section 14.2), and geriatric psychiatry (Section 51.1b). Social influences on help
seeking are discussed in Section 5.3 (mental health services research).