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The Attitudes of Social WorkStudents and PracticingPsychiatric Social WorkersToward the Inclusion in theCommunity of People withMental IllnessChaya Schwartz PhD aa School of Social Work , Bar-Ilan University , Ramat-Gan, 52900, IsraelPublished online: 23 Sep 2008.

To cite this article: Chaya Schwartz PhD (2003) The Attitudes of Social Work Studentsand Practicing Psychiatric Social Workers Toward the Inclusion in the Community ofPeople with Mental Illness, Social Work in Mental Health, 2:1, 33-45, DOI: 10.1300/J200v02n01_03

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The Attitudes of Social Work Studentsand Practicing Psychiatric Social WorkersToward the Inclusion in the Community

of People with Mental Illness

Chaya Schwartz, PhD

ABSTRACT. This study measured and compared the attitudes of socialwork students and practicing psychiatric social workers to the inclusionin the community of people with mental illness. The Community LivingAttitude Scale Mental Illness (comprising the four subscales of Empow-erment, Exclusion, Sheltering, and Similarity) was administered to a ran-dom sample of 68 Israeli BA social work students (first year: n = 35;third year: n = 33) and 28 practicing psychiatric social workers. Overall,the participants endorsed Empowerment and perceived the Similarity ofpersons with mental illness to themselves more than they agreed with theExclusion attitude of segregating those persons from community life.First-year students rated Empowerment and Similarity significantlylower than did the third-year students and rated Sheltering significantlyhigher than did psychiatric social workers. Psychiatric social workersdid not differ from third-year students and did not have stronger attitudi-nal commitment to the inclusion paradigm. They differed from first-yearstudents only in the sheltering attitude; they showed lower support forsheltering people with mental illness. [Article copies available for a feefrom The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail ad-dress: <docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com>© 2003 by The Haworth Press, Inc. All rights reserved.]

Chaya Schwartz is affiliated with the School of Social Work, Bar-Ilan University,Ramat-Gan, 52900, Israel (E-mail: schwartz@mail.biu.ac.il).

Social Work in Mental Health, Vol. 2(1) 2003http://www.haworthpress.com/web/SWMH

2003 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J200v2n01_03 33

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KEYWORDS. Attitudes, mental illness, inclusion, social work stu-dents, practicing psychiatric social workers

Deinstitutionalization and community care are the most influentialmovements in the mental health field in the past 30 years in many parts ofthe world, including the U.S., Europe, and Israel (Yip, 2001; Hastings,Sjostorm, & Stevenage, 1998; Aviram, 1990). These changes have in-cluded the expansion of community-based residences, which have be-come an alternative living arrangement to both the family home and theinstitution. This policy shift stems, it is believed, both from resistance toinstitutionalization and the emergence of attitudes favoring full societalinclusion. There has been a growing acceptance by professionals andsocial service agencies of the concept of community living for peoplewith mental illness, a concept involving physical as well as social integra-tion. It means integration into the social mainstream (mainstreaming)(Emerson, 1992). In practical terms, it means enabling persons with dis-ability to live and work in the least restrictive environment possible, en-abling them to use regular services as far as possible, allowing themautonomy and the right to take risks, to exercise control over their ownlives, and to enjoy real participation in community life. The centralprinciple of deinstitutionalization and community living is the idea ofnormalization, the essence of which is making the lives of these individ-uals as close as possible to ordinary life. Over the last ten years, therehas been increasing emphasis on adding to this the dimensions of self-ad-vocacy and empowerment (Henry, Keys, Balcazar, & Jopp, 1996).

Social integration and normalization emphasize that the success ofrehabilitation and community care of people with mental illness re-quires an accepting community. People with mental illness are affectedby stigma that causes discrimination and interrupts social inclusion.This stigma is not only prevalent in general society, but also among allhelping professions, including psychiatry, psychology, and social work(Shor & Sykes, 2002). Mental health professionals’ attitudes towardcommunity inclusion are important because of the relationship betweenattitudes and behavior (Antonak & Livneh, 1988). Researchers havebeen attempting to identify the extent to which attitudes can be used topredict behavior. For the most part, these approaches assume simplemodels of human behavior and attitudes, that is, that a single attitude,when properly assessed, corresponds to a single behavior and vice versa(Coursey, Curtis, Marsh, Campbell et al., 2000). Recent definitions ofattitude rely on the multidimensional approach. Attitudes are seen as

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being comprised of three major components: belief, affect, and behav-ior. An attitude, then, is a positive or negative reaction to an object, ac-companied by specific beliefs that tend to impel the individual in aparticular way toward an object (Yuker, 1976). The importance ofstudying the attitudes of mental health professionals toward communityinclusion of individuals with mental disorders is based on the assump-tion that these attitudes significantly influence patient-staff interactionsand are indirect, easily obtainable measures of staff effectiveness, andplay a role in the success of the therapeutic effort (Geskie & Salsek,1987). Another assumption is that changes in attitudes produced a cor-responding change in behavior. It is assumed that certain attitudes are“better” or more therapeutic than others. Cohen and Struening (1965)lent support to this belief with findings that patients from hospitals char-acterized by an authoritarian and restrictive atmosphere spent less timein the community after admission to the hospital than patients from hos-pitals with a less authoritarian restrictive atmosphere.

In addition to the effect on direct interactions with clients, profes-sionals’ attitudes may also have an impact on the way clients interactwith the external networks. The mediation of professionals betweenpeople with mental illness and the community has become increasinglyimportant with the emergence of the community care paradigm. Theprofessionals’ role is also to advocate on behalf of people with mentalillness in a variety of community forums. If professionals are to be in-strumental in mediating social integration, the starting point must betheir own attitudes.

Given the significance of professional attitudes, the importance oftheir appropriate measurement is self-evident. In addition, it is also ofinterest to examine attitude changes throughout their professional edu-cation period.

The present study used an attitude measure developed especially toassess attitudes to the emerging paradigm of community inclusion. Thisstudy examined attitudes of first- and third-year social work studentsand practicing psychiatric social workers toward the inclusion in thecommunity of people with mental illness. The rationale of this compar-ative design was based on Allport’s (1954) Contact Theory. Contact isoperationally defined as situations in which person-to-person interac-tion takes place–situations that allow a transition from depersonaliza-tion of the “out-group” to a more personalized accepting view (Makas,1993). Attitudes toward people with mental illness are influenced by anindividual’s familiarity with mental illness. Familiarity has been definedas knowledge of and experience with mental illness (Corrigan, Green,

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Lundin, Kubiak, & Pen, 2001). The study hypothesized that as theamount of professional education and the familiarity with mental illnessincreased, participants would exhibit more favorable attitudes towardthe inclusion in the community of people with mental illness.

Earlier studies have found that attitudes toward persons with mentalillness are related to such background factors as formal education(Pearson & Man-Yik, 1993; Lau & Cheung, 1999), gender (Livneh,1984; Florian, Weisel, Kravetz, & Shurka-Zernitsky, 1989), and age(Pearson & Man-Yik, 1993). Therefore, gender, age, and marital statuswere included as intervening variables.

METHOD

Research Population and Data Collection

During the last semester of the 2002 academic year, 70 first- andthird-year BA social work students were randomly selected from oneIsraeli school of social work that has a tradition of emphasizing commu-nity elements of social work practice.

In addition, 35 psychiatric social workers were included who werefield instructors in different agencies in which social work studentswere doing their third-year fieldwork. The reason to include first- andthird-year students was a desire to examine the influence of one year offieldwork in a mental health agency on attitude change. The studentsdidn’t have prior work experience with the mentally ill before enteringthe school of social work. Third- year students had completed 8 monthsof fieldwork in mental health clinics (as part of the fieldwork require-ments). For them, this was their first experience working with personswith mental illness. Each student worked with three patients using so-cial casework interventions and with one group using social group workinterventions. All the students received 2 hours of supervision a week.The participants volunteered to answer the questionnaire, and confiden-tiality was assured.

The personal characteristics of the participants are presented in Table1. The majority of the participants in the three groups were women whowere born in Israel. Differences were found between the two groups ofstudents and the psychiatric social workers regarding age and maritalstatus. The two groups of students were younger (although older thanBA students in other countries because of 3 years’ compulsory militaryservice commencing at the age 18), and the majority was unmarried.

36 SOCIAL WORK IN MENTAL HEALTH

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The psychiatric social workers were older and the majority was mar-ried. The psychiatric social workers were experienced social workersand most had an MA degree in social work.

Research Instruments

Demographic questionnaire: A short demographic questionnairewas used to gather data on the interviewee’s gender, age, marital status,country of origin, and presence of family members with mental illnessin the family. Students were asked on the year of study of academic edu-cation. Similarly, psychiatric social workers were asked about the ex-tent of experience in social work and in the field of mental health.

Community living attitude scales: To measure attitudes to the inclu-sion of people in the community with mental illness, a Hebrew versionof the Community Living Attitudes Scales–Mental Illness (CLAS-MI),developed by Henry, Keys, Balcazar, and Jopp (1996), was used. It wastranslated into Hebrew and validated by Schwartz and Armony-Sivan(2001). The CLAS-MI comprises four scales:

1. Empowerment: Attitudes to self-advocacy and empowerment.The 13 items relate to the rights of persons with mental illness tomake their opinions felt in decisions and policies affecting theirlives. The specific item content stresses self-advocacy, self-direc-tion, choice, and mutual help.

2. Exclusion: The common theme of these 8 items is the desire tosegregate persons with mental illness from community life. Allitems have a negative affective tone.

3. Sheltering: These 7 items measure the extent to which the respon-dent believes that persons with mental illness need to have otherssupervise them in their daily lives or protect them from the dan-gers of community life. High scores on this subscale might indi-cate an endorsement of separation for the sake of protection, butwithout the negative affective tone of the Exclusion subscale.

4. Similarity: These 12 items measure the perceived similarity ofpersons with mental illness to the respondent in areas as diverse aslife goals and basic human rights.

The study hypothesized that respondents endorsing empowermentwould oppose exclusion and that attitudes measuring opposition to ex-clusion are likely to co-occur with the attitude that persons with mentalillness are basically similar to people in general.

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Respondents indicated the extent to which they agree with each itemon a 6-point Likert scale ranging from 1 (strongly disagree) to 6(strongly agree). Roughly half of the items were reverse-worded to con-trol for response sets. The Cronbach alpha reliability coefficient of theCLAS-MI Scales, as reported by Henry and his colleagues (1996),ranged from 0.75 to 0.86. In the Hebrew version, a similar level of inter-nal reliability was obtained. Schwartz and Armony-Sivan (2001) re-ported an internal reliability that ranged from 0.70 to 0.85, and, in thisstudy, that the CLAS-MI subscales demonstrated acceptable internalreliability that ranged from 0.70 to 0.81.

RESULTS

Data Analysis

To compare the attitudes of participants, scores were calculated foreach respondent on each of the four attitude subscales. Dividing eachrespondent’s total score on each subscale by the number of items in thatsubscale standardized their scores. The major statistical tool employedwas a one-way MANOVA. This test was intended to discover if therewere any differences between the three groups of respondents with re-

38 SOCIAL WORK IN MENTAL HEALTH

TABLE 1. Participants’ Personal Characteristics by Group

Characteristic: First-YearStudents(N = 35)

Third-YearStudents(N = 33)

PsychiatricSocial Workers

(N = 28)

Gender:FemaleMale

29 (83%)6 (17%)

30 (90%)3 (10%)

24 (85%)4 (15%)

Age M = 24.26 (5.05)Range 20-42

M = 24.72 (3.46)Range 22-41

M = 40.89 (9.15)Range 26-52

Born in Israel 23 (66%) 24 (75%) 20 (71%)

Marital status:MarriedSingle/divorced/widowed

6 (17%)29 (83%)

7 (21%)26 (79%)

23 (82%)5 (18%)

Social work education:B.A.M.A.

__ __ 3 (11%)25 (89%)

Work experience insocial work (in years)

Work experience in men-tal health (in years)

__ __

M = 13.57 (9.21)Range 2-29

M = 11.29 (8.89)Range 2-26

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gard to the 4 subscales. Univariate Anova analyses were undertaken toexamine the differences between the groups with regard to a specificsubscale. The analysis was followed by a Scheffe test to identify thesource of difference. MANCOVA analysis was undertaken with regardto age, while MANOVA analyses were undertaken with regard to gen-der and marital status. These tests sought to discern whether differencesbetween the groups were a result of demographic differences.

Attitude Differences

The mean scores received regarding each of the four attitude subscalesare presented in Figure 1. The error bars indicate the size of the standarddeviation on each scale.

From the figure, we see that participants in the three groups endorsedempowerment and perceived similarity of persons with mental illnessto themselves more than they agreed with the exclusion attitude. Figure1 shows that the rating of the attitude scales by participants differed.The differences were found to be significant with regard to three out ofthe four attitude scales: Empowerment [F (2,93) = 5.14; p < . 01], Shel-tering [F (2,93) = 3.01; p < .05] and Similarity [F (2,93) = 2.99; p < .05].In a Scheffe test, it was found that first-year students rated the empow-erment scale and the similarity scale significantly lower than did thethird-year students and rated the sheltering scale significantly higherthan psychiatric social workers. Third-year students rated the four atti-tude scales higher than did psychiatric social workers, but the differ-ences were not significant.

There were no significant interactions between the group the partici-pants were related to and the demographic variables: gender, age andmarital status, on the four attitude scales.

DISCUSSION

Overall, students and psychiatric social workers endorsed empower-ment and they perceived similarity of persons with mental illness tothemselves more than they agreed with the exclusion attitude (segregat-ing those persons from community life). Apparently, care policies forpeople with disabilities based on the principles of normalization andcommunity integration are beginning to be accepted and do indeed leadto positive attitudes to the presence of such people in the community. Thepositive attitudes of first-year social work students toward the pres-

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ence in the community of people with disabilities were reported in an-other study (Schwartz & Armony-Sivan, 2001). In that study the first-year social work students expressed more positive attitudes than first-year students in law, the natural sciences, and the social sciences. It ap-peared that people who choose to study social work differ from studentsin other major fields in that they tend to have more positive attitudes to-wards people with disabilities.

Third-year students expressed more positive inclusion attitudes to-ward people with mental illness than first-year students. Perhaps themore positive attitudes are the result of a one-year fieldwork experiencein mental health care settings. Fieldwork plays a critical role in socialwork education since the founding of the first professional school of socialwork in 1898 (Spitzer, Holden, Cuzzi, Rutter, Chernack, & Rosenberg,2001). Fieldwork is the pivotal element of professional preparation provid-ing initial opportunities to engage the student in applied use of theirnewly acquired knowledge, skills, and abilities. As such, the expe-

40 SOCIAL WORK IN MENTAL HEALTH

5

4

3

2

1

CLA

SR

atin

gs

Empo

werm

ent

Exclus

ion

Shelte

ring

Simila

rity

First-YearStudents

Third-YearStudents

Psychiatric S.W.

FIGURE 1. Means and Standard Deviations on the Community Living Atti-tude Scale–Mental Illness (CLAS-MI) for the Three Groups of Participants

Note: A higher mean score indicates a stronger agreement with the attitude, and the barsabove the histogram represent standard deviations.

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rience should be systematically patterned to allow for progressive expo-sure to the characteristics and demands of contemporary practice.Fieldwork in mental health care settings is worthy of sustained attentionbecause the majority of practicing psychiatric social workers reportedthat they did their fieldwork in mental health settings (Spitzer et al.,2001).

Examination of the impact of fieldwork in mental health care settingson tomorrow’s social workers is important also because it’s an educa-tional process employed in other disciplines that work with personswith mental illness like education, nursing, psychology, and medicine.An important emerging strategy for bringing about changes in helpingprofessions students’ perceptions of people with mental illness mightbe providing students with direct exposure to people with mental ill-ness. In isolation, academic instruction does not alter attitudes regard-ing people with mental illness to the same extent as instruction coupledwith practical experience. A few recent studies showed that a one-yearpsychiatric education program positively influenced the attitudes ofmedical students toward people with mental illness (Baxter, Singh,Standen, & Duggan, 2001; Mino, Yasuda, Tsuda, & Shimodera, 2001;Singh, Baxter, Standen, & Duggan, 1998; Tharyan, John, Tharyan, &Braganzaa, 2001).

The findings with regard to the impact of fieldwork in mental healthcare settings on attitude change support Allport’s (1954) hypothesisthat proposed that only through personal contact can one discover themerits of a target and discount its ostensible defects. This general hy-pothesis is applicable to one’s interaction with persons with mental ill-ness and one’s attitude towards them. Interaction can dispel one’sstereotypic perception of these people. Through contact, one learnsabout their positive characteristics. Positive information can eliminatenegative beliefs and attitudes. According to social learning theory, aperson with more knowledge and experience about people with disabil-ities might perceive himself as self-efficacious to interact with them(Stroebe & Insko, 1989). According to psychoanalytic theory, thisknowledge and experience might reduce psychological insecurity andthereby may improve one’s acceptance of out groups by suppressing theauthoritarian tendency that legitimizes the use of aggression and dis-crimination against people with disabilities (Stroebe & Insko, 1989).

In this study, we did not find that experienced psychiatric socialworkers differed from third-year students in having a stronger attitudi-nal commitment to the inclusion paradigm. Experienced social workersdiffered from first-year students only in the sheltering attitude; they

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showed a lower support about sheltering people with mental illness.There are two possible explanations for these findings: (1) the relativeintensity of their contact with persons with chronic mental illness, and(2) their criticism about the implementation of the community carepractice. Experienced psychiatric social workers among other experi-enced health professionals tend to be more pessimistic about the out-come of mental illness because of greater contact with patients withchronic or recurrent disorders (Jorm, Korten, Jacomb, Christensen, &Henderson, 1999). From the other hand, it is also possible that thegreater contact leads these professionals to believe that people withmental illness are capable of managing the dangers of community life,and, therefore, they are not in as great need of sheltering as most peoplemight believe.

In addition, like other professionals, they have some disappointmentabout community care for people with mental illness. They claimed thatto implement community care, it is necessary to add more resources andthat the government’s commitment was slim and insufficient (Lamb &Shaner, 1993; Aviram, 1990; Ajzenstadt, Aviram, Kalian, & Kanter,2001). A few have even begun to ask whether the present communityprograms and services can successfully treat and take care of chronicmentally ill patients (Yip, 2001).

Certain limitations of our study should be acknowledged. This wasnot a longitudinal follow-up study, and we did not use comparisongroups in order to control for attitude change occurring as a function oftime and extraneous influences. Another limitation is that there was norandom assignment of students to receive rotations in services for per-sons with chronic mental illness. The findings may not be generalizableto social work students in other countries where the entry degree to theprofession is a postgraduate degree and not a BA.

Historically, social work as a profession has been involved in the de-velopment of the community care movement (Yip, 2001). Therefore,social work education is so crucial. The great expansion of commu-nity-based services for people with disabilities has made the shortage ofappropriately trained professionals, including social workers, a matterof great concern (Werrbach & DePoy, 1993; Henry, Keys, Balcazar, &Jopp, 1996). The findings of our study would seem to bring some com-fort with regard to the long-term realization of the community-livingparadigm. First, third-year social work students displayed a positive re-sponse to the paradigm, and perhaps after graduation they might beready and willing to work with mentally ill persons living in the com-munity. Second, their educational program had a positive impact on

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their attitudes towards community care practice. These findings wouldseem to bring some hope that those future social workers will be respon-sible for developing an accepting community. Attention should begiven to the relatively pessimistic attitudes of the experienced psychiat-ric social workers toward the community-living paradigm. These atti-tudes might lead to stigmatization. With respect to mental illness,studies indicated that stigma continues to complicate the lives of thestigmatized even as treatment improves their symptoms and function-ing (Link, Struening, Rahav, Phelan, & Nuttbrock, 1997). If socialworkers want to maximize the well-being of the people they treat, theymust address stigma as a separate and important factor in its own right.

Measuring attitudes of future students of disciplines that work withpersons with mental illness should be a target for future studies, espe-cially in countries where economic pressures and budget cuts can turnsocietal attitudes against the full societal inclusion of people with dis-abilities. Future research should take the form of longitudinal follow-upstudies.

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