11/9/2020 Article: Scaling Community Attitudes Toward the Mentally Ill | CAMI Scale

Article: Scaling Community Attitudes

Toward the Mentally Ill

Scaling Community Attitudes Toward the Mentally III

by S. Martin Taylor and Michael J. Dear

Abstract
The measurement of public attitudes toward the mentally ill has taken on new
signi cance since the introduction of community-based mental health care.
Previous attitude scales have been constructed and applied primarily in a
professional context. This article discusses the development and application of a
new set of four scales explicitly designed to measure community attitudes toward
the mentally ill. The scales represent dimensions included in previous instruments,
speci cally, authoritarianism, benevolence, social restrictiveness, and community
mental health ideology, but are expressed in terms of an almost completely new set
of items that emphasize community contact with the mentally ill and mental health
facilities. Data from a study of community attitudes about neighborhood mental
health facilities in Toronto are used to test the internal and external validity of the
scales. Results of the analysis provide strong support for the validity of the scales
and demonstrate their usefulness as explanatory and predictive variables for
studying community response to mental health facilities.

In both America and Canada, the move toward community-based mental health care has
caused extensive neighborhood opposition. The media often seem to delight in reporting
the negative aspects of community care, such as erratic client behavior or residents’ fear of
property value decline. Geographical interest in this topic stems from two sources: rst,
because citizen opposition can block the siting of a mental health facility, and thereby
upset the pattern of client accessibility to a decentralized service system; and secondly,
because proximity to mental health centers apparently intensi es opposition, leading to
spatial variation in community cognition and perception of facilities.
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The purpose of this article is to provide an instrument for the systematic description of
community attitudes toward the mentally ill. Previous research has suggested that the
social reintegration of ex-psychiatric patients depends crucially upon their acceptance (or
rejection) by the host community. Accordingly, we wish to develop scales to measure
Community Attitudes Toward the Mentally 111, which will aid in the assessment and
prediction of the host community’s reactions. In order to achieve its purpose, the article
rst reviews existing approaches to the study of attitudes toward the mentally ill. Secondly,
the sample frame and database for this study are brie y outlined. Thirdly, the
development of the scales is described, and their validity and utility in predicting
community reaction are demonstrated. Finally, some comments on the future applications
of the scales are o ered.

Existing Studies of Attitudes Toward the Mentally III

Geographical interest in mental health care delivery has expanded rapidly during the past
decade. Although Smith (1977) has outlined the broad areas of concern in this eld,
research e orts are only now becoming more coordinated and purposeful. Five themes
seem to be gaining prominence in the geographic literature:

Descriptions of the geographical incidence of mental illness, and its ecological correlates
(e.g., Giggs 1973 and Miller 1974).
Studies in the utilization and accessibility of mental health services (Dear 1977a; Holton,
Krame, and New 1973; Smith 1976; Joseph 1979).
Follow-up studies of the aftercare problems of patients discharged from psychiatric
hospitals (Smith 1975; Wolpert and Wolpert 1976; Dear 1977b).
Analyses of neighborhood opposition to the location of community mental health
facilities (Wolpert, Dear, and Crawford 1975; Boeckh, Dear, and Taylor 1980).
Structural analyses of the community support system for the mentally disabled and
other service-dependent populations (Gonen 1977; White 1979; Wolpert 1978; Wolch
1979).

The approach taken in this article derives from the fourth of these themes, but also
integrates two other research themes from the psychiatric literature. The rst is the
substantive documentation of attitudes toward the mentally ill; and the second is the
methodological literature on attitude measurement. Because both these elds have been
extensively reviewed elsewhere, our purpose here is merely to indicate the major
antecedents of our approach.

In the rst instance, our work is indebted to the major synthesis on attitudinal research
provided by Rabkin (see, for example, Rabkin 1974). She has recorded the increasing
volume of research since 1945 on community attitudes, and has recently warned that the

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steady improvement in community attitudes may have reached a “plateau,” and that
current trends in deinstitutionalization may threaten a decline in acceptance (Rabkin
1980). Closely related to this work is the research of Segal and his associates into the
dimensions of accepting and rejecting host communities. In an extensive series of reports,
Segal has suggested that the reintegration of the mentally ill is closely linked to the
characteristics of the host community, of the facility itself, and of its residents (Segal and
Aviram 1978). Facilities with the highest level of integration tend to be in neighborhoods
with low social cohesion (e.g., downtown areas, with a highly transient population). On the
other hand, social integration tends to be lower in highly cohesive neighborhoods (e.g.,
suburban single-family subdivisions), which tend to close ranks against the incursion of the
mentally ill (Trute and Segal 1976).

Against this background of acceptance or rejection and integration or exclusion, we

searched a second literature in order to develop a scaling instrument for community
attitudes. While there existed several di erent scaling instruments for measuring
professional attitudes toward the mentally ill, very little e ort appears to have been made
to develop such instruments for assessing community attitudes. Accordingly, we used the
two most comprehensive and best-validated of existing scales, the Opinions about Mental
Illness (OMI) and Community Mental Health Ideology (CMHI) scales, and adapted them to
develop our Community Attitudes Toward the Mentally III (CAMI) scales.

The OMI scales were originally developed in a study of the attitudes of hospital personnel
toward mental illness (Cohen and Struenin’g 1962). The OMI comprises ve Likert scales
that were empirically derived from factor analysis of a pool of 100 opinion statements. The
statement pool was compiled primarily to re ect a range of sentiments about mental
illness and the mentally ill, but it also drew upon existing scales such as the Custodial
Mental Illness Ideology Scale (Gilbert and Levinson 1956), the California F scale (Adorno et
al. 1950), and Nunnally’s (1961) multiple item scale. The ve OMI scales were labeled as
follows: authoritarianism, re ecting a view of the mentally ill as an inferior class requiring
coercive handling; benevolence, a paternalistic, sympathetic view of patients based on
humanistic and religious principles; mental hygiene ideology, a medical model view of
mental illness as an illness like any other; social restrictiveness, viewing the mentally ill as a
threat to society; and interpersonal etiology, re ecting a belief that mental illness arises
from stresses in interpersonal experience.

Baker and Schulberg (1967) developed a multiple item scale designed speci cally to
measure an individual’s commitment to a community mental health ideology. The
Community Mental Health Ideology (CMHI) scale comprises 38 opinion statements
expressing three di erent aspects of the basic ideology. The conceptual categories focus
on characteristics of the total population, rather than merely those seeking psychiatric
help; primary prevention, including e orts via environmental intervention; and total
community involvement in working with a variety of community resources to assist patients.

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The scale has been shown to discriminate e ectively between groups known to be highly
oriented toward this ideology and random samples of mental health professionals.

The OMI and CMHI scales were the basis for measuring attitudes toward the mentally ill in
the present study. They were substantially revised with the dual objectives of (1)
emphasizing community rather than professional attitudes toward the mentally ill, and (2)
reducing the total number of items. Before proceeding with the development of the CAMI
scales, we will outline the empirical framework of our study.

A Survey of Community Attitudes in Metropolitan Toronto

The major purpose of our study was to analyze the basis for community opposition to
community mental health facilities, with the twin goals of determining the characteristics
of “acceptor” and “rejector” neighborhoods and of developing planning guidelines for
locating those facilities (Dear and Taylor 1979). Data on attitudes and other resident
characteristics were obtained in 1978 by a questionnaire survey of residents in
Metropolitan Toronto. A random sample was selected from the total population strati ed
by three levels of socioeconomic status (high, medium, and low) and two levels of
residential location (city and suburb). Separate samples were drawn from areas with and
without existing community mental health facilities. The total sample was 1,090
households, 706 from areas without a facility and 384 from areas having a facility. Three
types of facility were included in the with-facility sample: outpatient units, group homes,
and social-therapeutic (drop-in) centers.

The questionnaire was introduced as a survey of attitudes toward community services;

mental health facilities were not mentioned at the outset, and the rst three questions
asked for general opinions. Subsequent questions elicited information on awareness of
neighborhood mental health facilities; attitudes toward the mentally ill (using the CAMI
scales); various perceptual, attitudinal, and behavioral reactions to facilities; and personal
characteristics. Three parts of this questionnaire are relevant here. First, all 1,090
respondents completed the CAMI scaling instrument. Secondly, they were asked to
indicate the desirability of having a potential facility within three di erent distance zones
from their residence: within 1 block; 2-6 blocks; and 6-12 blocks. Respondent ratings were
measured on a 9-point labeled scale ranging from “extremely desirable” (1) to “extremely
undesirable” (9), with the midpoint (5) as “neutral.” The behavioral response of
respondents to the introduction of a facility into their neighborhood was also determined.
Finally, all those respondents who were aware of any facility in their neighborhood (n =
132, even though 384 respondents were selected because they lived within one-quarter of
a mile of a facility) were asked if they were in favor of, opposed to, or indi erent toward it.
Standard socioeconomic and demographic data were also collected for each respondent.

It is important to point out that highly speci c labels were devised for use in the survey.
Community mental health facilities were de ned for the respondent as including

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Outpatient clinics, drop-in centers, and group homes which are situated in residential
neighborhoods and serve the local community. Mental health facilities which are part
of a major hospital are NOT included.

A similar precision was introduced in the de nition of the mentally ill, who were
characterized as

People needing treatment for mental disorders but who are capable of independent
living outside a hospital.

This de nition was used to emphasize our focus on the nonhospitalized patient and to
re ect the general competence level of users of community mental health facilities in the
Toronto area.

Development of the CAMI Scales

Scale Selection. Two related objectives directed the development of scales to measure
community attitudes toward the mentally ill. The rst was to construct an instrument able
to discriminate between those individuals who accept and those who reject the mentally ill
in their community. The second was to develop scales to predict and explain community
reactions to local facilities serving the needs of the mentally ill. Previous research, as
already discussed, shows that attitudes toward mental illness are multidimensional. Given
our objectives, it did not seem necessary to construct scales to measure all possible
dimensions but rather to focus on those dimensions that are the most strongly evaluative
and hence best discriminate between those positively and negatively disposed toward the
mentally ill and mental health facilities. To this end, we identi ed three of the OMI scales
(authoritarianism, benevolence, and social restrictiveness) and the CMHI as the most useful
existing scales for our purposes.

These four scales in their original form were not appropriate for our Toronto research for
two reasons. First, the scales were developed with professionals in mind as the potential
respondents. It was therefore necessary to modify them for use in a general population
survey. Second, for some of the scales, the number of items was excessive for use in a
community survey—particularly when, as in our case, many questions besides attitudes
toward mental illness were to be included in the questionnaire. Scale construction for the
Toronto study therefore essentially involved developing shortened and revised versions of
the original scales to emphasize community rather than professional attitudes toward the
mentally ill.

Item Pool. The item pool for pretest purposes comprised 40 statements, 10 for each of
the 4 scales. Only 7 of the 40 came from the original OMI and CMHI scales: three for
authoritarianism, two for benevolence and social restrictiveness, and none for community
mental health ideology. Four additional authoritarianism items came from the Custodial
Mental Illness Ideology Scale (CMI) developed by Gilbert and Levinson (1956). For the three
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OMI scales, the new statements do not alter signi cantly the content domains of the scales
as originally conceived by Cohen and Struening (1962). Their e ect is to emphasize those
facets of the content domains which impinge most directly on community contact with the
mentally ill. For the CMHI scale, the revisions are more fundamental because the original
statements were clearly intended for application in a professional context, and hence a
completely new set of statements was required for community-based research. These new
statements shift the focus of the scale from the professional’s adherence to the general
principle of community mental health, as emphasized in the Baker and Schulberg scale, to
the acceptance by the general population of mental health services and clients in the
community. The themes expressed in the new scales are summarized in the following
descriptions.

Sentiments embedded in the authoritarianism statements were: the need to hospitalize the
mentally ill (i.e., As soon as a person shows signs of mental disturbance, he should be
hospitalized); the di erence between the mentally ill and normal people (e.g., There is
something about the mentally ill that makes it easy to tell them from normal people); the
importance of custodial care (e.g., Mental patients need the same kind of control and
discipline as an untrained child); and the cause of mental illness (e.g., The mentally ill are
not to blame for their problems). For benevolence, the sentiments were: the responsibility
of society for the mentally ill (e.g., More tax money should be spent on the care and
treatment of the mentally ill); the need for sympathetic, kindly attitudes (e.g., The mentally
ill have for too long been the subject of ridicule); willingness to become personally involved
(e.g., It is best to avoid anyone who has mental problems); and anticustodial feelings (e.g.,
Our mental hospitals seem more like prisons than like places where the mentally ill can be
cared for).

The social restrictiveness statements tapped the following themes: the dangerousness of
the mentally ill (e.g., The mentally ill are a danger to themselves and those around them);
maintaining social distance (e.g., A woman would be foolish to marry a man who has
su ered from mental illness, even though he seems fully recovered); lack of responsibility
(e.g., The mentally ill are very unpredictable and should not be given any responsibility);
and the normality of the mentally ill (e.g., Many people who have never had psychiatric
treatment have more serious mental problems than many mental patients). For the CMHI
scale, statements expressed these sentiments: the therapeutic value of the community
(e.g., The best therapy for many mental patients is to be part of a normal community); the
impact of mental health facilities on residential neighborhoods (e.g., Locating mental
health facilities in a residential area downgrades the neighborhood); the danger to local
residents posed by the mentally ill (e.g., It is frightening to think of people with mental
problems living in residential neighborhoods); and acceptance of the principle of
deinstitutionalized care (e.g., Mental hospitals have a very limited role to play in a civilized
society).

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Five of the 10 statements on each scale expressed a positive sentiment with reference to
the underlying concept, and the other ve were negatively worded. For example for the
authoritarianism scale, ve statements expressed a pro-authoritarian sentiment, and ve
were anti-authoritarian. The response format for each statement was the standard Likert
5-point labeled scale: strongly agree/ agree/neutral/disagree/strongly disagree. The
statements were sequenced in 10 sets of 4, and within each set, the statements were
ordered by scale—authoritarianism, benevolence, social restrictiveness, and community
mental health ideology. The aim of this sequencing was to minimize possibilities of
response set bias.

Pretest Results. Two separate pretests were conducted to assess the reliability and
validity of the statements and scales. The rst was based on a group of rst year
undergraduate students in urban geography (n = 321) at McMaster University and the
second on the respondents (n = 54) in a eld pretest conducted by the York University
Survey Research Centre. For both sets of data, item-total correlations and alpha
coe cients were calculated as measures of statement and scale reliability (Nunnally 1967).

When the results from both pretest samples (table 1) are considered, the alpha
coe cients for all four scales are above .50, which can be regarded as a satisfactory
(though modest) level of reliability in the early stages of scale construction. The coe cients
are notably higher for the McMaster student group for three of the scales (except
authoritarianism), which have relatively strong alphas above .70.

Although the scales are in general satisfactory, inspection of the statement-scale

correlations shows a number of statements that make very little contribution to their
parent scale. These statements were replaced by statements expressing similar
sentiments to those contained in statements more strongly correlated with total scale
scores. In addition, two statements on the social restrictiveness scale were replaced to
eliminate unnecessary repetition.

Statement and Scale Reliability and Validity for Final Data. The same statistics were
calculated to test the reliability and validity of the revised scales using the full Toronto data
set (n = 1,090). The alpha coe cients (table 1) are in all cases but one higher than the

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pretest values, the one exception being on the benevolence scale where the coe cient for
the nal scale is marginally lower than for the McMaster pretest. Three of the four scales
have high reliability: CMHI (a = .88), social restrictiveness (a = .80) and benevolence (a = .76).
The coe cient for authoritarianism (a = .68), though lower, is still satisfactory. These
increases in the alpha values re ect the general strengthening of the item-total correlation
for statements retained from the pretest, and the improvement due to the replacement of
the statements shown to be weak in the pretest results.

The construct validity of the nal scales was assessed by testing their empirical
reproducibility using factor analysis. A four-factor orthogonal solution accounting for 42
percent of the variance was obtained (table 2). Factor scores were calculated and
correlated with the raw scores on the four a priori scales. The matrix of correlations among
the a priori and factor scales (table 3) is revealing in two respects. First, it shows a high
degree of intercorrelation among the a priori scales. The lowest correlation is -.63 between
authoritarianism and benevolence, and the highest is -.77 between social restrictiveness and
CMHI. These coe cients can in part be compared with those reported in previous studies
using the OMI (Fracchia et al. 1972). In general, the correlations in this case are higher,
possibly re ecting the fact that the distinctions between the scales are not so clear to the
general population as they are to the professionals who were respondents in the earlier
studies. More importantly, the di erence may also re ect the revisions made to the scales
for this study.

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The correlation matrix (table 3) shows secondly a reasonable degree of correspondence

between the a priori and factor scales—the desired result from a constant validity
standpoint. The CMHI scale is strongly identi ed with the second factor (r = .86), and the
benevolence scale is almost as strongly identi ed with the third factor (r = .81).
Authoritarianism and social restrictiveness are approximately equally correlated with the
rst factor and, to a lesser extent, with the fourth factor. This provides some evidence that
these two scales perhaps represent a single dimension. They are treated separately,
however, in the subsequent analyses. The remaining coe cients in the lower right of the
matrix show the low correlation among the factor scales. This is an artifact of the
algorithm, which forces independence between the factors within an orthogonal solution.

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Correlates of Attitudes Toward the Mentally III

The theoretical framework for the Toronto study (Dear and Taylor 1979, chapter 2) is that
attitudes toward the mentally ill are a function of a combination of personal characteristics
including socioeconomic status, life cycle state, and personal beliefs and values. Existing
research on attitudes toward the mentally ill provides some support for the importance of
these factors (see Rabkin 1974). The same theoretical framework shows that attitudes
toward the mentally ill are the major in uence on reactions to mental health facilities. The
construct and predictive validity of the attitude scales within this theoretical framework
can therefore be examined by analyzing their relationship with, on the one hand, various
personal characteristics and, on the other, measures of response to mental health
facilities.

Personal Characteristics and Attitudes Toward the Mentally Ill. Three subsets of
personal characteristics were distinguished for this analysis: demographic, socioeconomic,
and belief variables. Demographic characteristics were measured by four variables: sex,
age, marital status, and number of children in three age groups (under 6, 6 to 18, and over
18). Socioeconomic status was measured in conventional terms by educational level,
occupational status (both respondent and head of household) and household income, and
in addition, by tenure status. Personal beliefs and values were not measured directly. A
proxy measure is included in terms of church attendance and denominational a liation.
Also included as a factor a ecting beliefs and attitudes toward the mentally ill is a measure
of familiarity with mental illness based on whether the respondent or his/her friends or
relatives had ever used mental health services of any kind.

The variables used in the analysis represent di erent levels of measurement—nominal,

ordinal, and interval/ratio. The speci c measurement properties of the paired combination
of variables determine the statistical test used. The CAMI scales are assumed to have
interval properties. Tests that relate attitudes to population characteristics with nominal
properties are based on a di erence of means test (t test) where the characteristic has two
categories (e.g., sex), and a one-way analysis of variance (F test) where there are more than
two categories (e.g., marital status). Relationships between population characteristics
measured on an ordinal scale (e.g., household income) and attitudes toward the mentally
ill are tested i by nonparametric correlation (Kendall’s tau). Finally, relationships involving
characteristics with interval properties (e.g., age) are tested by parametric correlation
(Pearson’s r).

Five of the six demographic variables examined show relatively strong relationships with
the four attitude scales, the exception being number of children over 18 (table 4).
Consistent with previous studies, older residents report less sympathetic attitudes toward
the mentally ill. This pattern occurs for all four scales. Older respondents in the Toronto
sample are in general more authoritarian, less benevolent, more socially restrictive, and
less community mental health oriented in their views.

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Stronger e ects for sex are found for these data than for results reported in previous
studies. The direction of the e ect shows more sympathetic attitudes among female
respondents. This emerges on three of the four scales. No signi cant di erence occurs for
social restrictiveness.

Highly signi cant di erences are found among marital status groups on all four scales.
Examination of the group mean on each scale reveals the pattern of the e ect. A basic
distinction emerges between the married and widowed groups and those single,
separated, or divorced—the former expressing the less sympathetic attitudes on each of
the four scales. These di erences in part re ect the age variation already observed and
the e ects of number and ages of children.

The number of children under 6 years and the number between 5 and 18 years show very
similar e ects, the latter being marginally stronger. In both cases, respondents with
children in these age groups are generally more authoritarian and socially restrictive and
correspondingly less benevolent and community mental health oriented. The lack of
signi cant e ects for number of children over 18 supports the expectation that parents
with older families will have fewer concerns about the mentally ill and their children’s
possible contact with them.

Taken together, these results indicate that the e ects of demographic characteristics on
attitudes toward the mentally ill are both statistically signi cant and consistent in their
direction. The variables included here, excepting sex, represent in combination a measure
of life-cycle status. The conclusion is therefore that attitudes toward the mentally ill vary
signi cantly by life-cycle stage.

Four of the ve socioeconomic measures show strong and consistent relationships with the
attitude scales, the exception being household income (table 5). The observed direction of

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the relationships con rms previous ndings: more sympathetic attitudes are characteristic
of higher status residents. This conclusion applies when status is measured in either
educational or occupational terms, though the relationships are somewhat stronger for
the education variable. Relationships with income, the third conventional measure of
socioeconomic status, are weaker and for two scales, benevolence and CMHI, are not
signi cant. This nding indicates that household income varies somewhat di erently
within the population than does education or occupation and that income is the least
e ective as a discriminator of attitudes toward the mentally ill.

The signi cant e ect of tenure status con rms the expectation that owners generally hold
less sympathetic attitudes than renters, possibly re ecting their greater vested interest in
protecting their daily life environment.

Within the subset of belief variables, church attendance and familiarity with mental health
care show signi cant relationships with all four attitude scales (table 6). Religious
denomination has a signi cant e ect on only the authoritarianism and benevolence scales.
The direction of the e ect for church attendance is that regular attenders are, on average,
less sympathetic in their views, tending to be more authoritarian and socially restrictive
and less benevolent and community mental health oriented. As could be expected, regular
attenders in general hold more conservative views. Among attenders, however, there are
signi cant denominational di erences for two of the scales. Of the 13 major
denominational groups distinguished in the survey, the Pentecostal and Greek Orthodox
groups emerge as the most authoritarian in contrast to the Baptists and Salvation Army,
who expressed the least authoritarian views. Correspondingly, the Baptist, together with
United Church, adherents held the most benevolent attitudes, again in contrast to the
least benevolent views of the Pentecostal and Greek Orthodox members.

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In terms of familiarity with mental health care, respondents who themselves had used
mental health services or whose friends or relatives had used them expressed more
sympathetic attitudes on all four scales. Personal experience of mental health care,
whether direct or indirect, therefore has a signi cant e ect on subsequent attitudes
toward the mentally ill and the provision of mental health services.

Considered overall, the pattern of these relationships provides further support for the
construct validity of the attitude scales. The relationships are consistent with the
hypotheses derived from the underlying theoretical framework and are also similar to
those reported in previous studies in which the personal correlates of attitudes toward the
mentally ill have been examined. These results, however, go beyond those previously
reported in that a broader range of personal characteristics was included in the analysis.

Attitudes Toward the Mentally Ill and Reactions to Mental Health Facilities. The
relationship between attitudes toward the mentally ill and reactions to mental health
facilities can be dealt with more brie y because we have discussed them in detail
elsewhere (Taylor et al. 1979). The purpose of examining these relationships in the context
of this article is to establish the predictive validity of the four scales.

For this analysis, reactions to facilities were measured in both attitudinal and behavioral
terms. All of the Toronto respondents (n = 1,090) rated the desirability of having a
hypothetical facility located within three di erent distances of their home: within 1 block, 2

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to 6 blocks, and 7 to 12 blocks. Ratings were on a 9-point labeled scale ranging from
“extremely desirable” to “extremely undesirable.” For each facility-distance combination
rated to any degree undesirable, respondents were asked what, if any, action they would
most likely take in opposition. They were shown a list of nine possible actions (table 7).
Respondents aware of an existing facility in their neighborhood were asked whether they
were in favor of, opposed to, or indi erent toward it. If opposed, they were asked, using
the same list, what actions they had taken. It is revealing that only 132 respondents were
aware of a facility in their neighborhood, even through 384 were selected on the basis of
living within a quarter mile of one.

The general hypothesis that reactions to facilities are related to attitudes toward the
mentally ill was tested rst by correlating scores on the four scales with the facility
desirability ratings for the three distance zones. The correlations (table 8) show highly
signi cant relationships between all four scales and the three separate desirability ratings.
Considered by attitude scale, the highest coe cient occurs for CMHI—the scale most
directly concerned with community mental health. The positive sign of the coe cients for
CMHI is consistent with the hypothesis that facility locations will be judged more desirable
by those expressing pro-CMHI sentiments.

After CMHI, the scale most strongly correlated with the desirability ratings is social
restrictiveness. This scale expresses the view that the mentally ill pose a threat to society
and that their activities should therefore be closely controlled and supervised. Those
holding a pro-social restrictiveness view would be predicted as judging neighborhood
mental health facilities as undesirable, and this is con rmed by the negative signs of the
coe cients. The coe cients for authoritarianism and benevolence are slightly lower, but
their signs con rm the working hypotheses. Pro-authoritarian views are associated with
less favorable ratings of facilities, and pro-benevolent sentiments coincide with more
favorable ratings.

Considered by distance zone, the correlations again show a consistent pattern. For each
scale, the coe cients increase with decreasing distance. This suggests that the variation in

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desirability ratings becomes increasingly systematic as the distance between facility and
residence decreases. As a result, attitudes toward the mentally ill best predict the judged
desirability of facility locations within a block of home.

For the analysis of relationships between attitudes toward the mentally ill and intended
opposition to facilities, the nine possible actions were reduced to four categories: no
action, individual action, group action, and consider moving (table 8). The pattern of the
relationships from the analyses of variance (table 9) is similar to that just described for the
desirability ratings. The relationships are strongest for CMHI and for the nearest distance
zone. None of the four scales are signi cantly related to intended actions for the 7-12
block zone. For the other two zones, benevolence is the only scale that is not signi cantly
related.

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Examining the mean scale scores for the four categories of intended action reveals the
pattern of the signi cant relationships. For example, in the case of the relationship with
CMHI for the nearest distance zone, those intending no action are on average the most
pro-CMHI, followed in order of describing community mental health orientation by those
intending a group action, those intending an individual action, and those who would
consider moving. The fact that the most community mental health oriented would do
nothing, and the least so would consider moving, provides further support for the
predictive validity of the CMHI scale. The ordering of the category means is equally
consistent for the other two scales having signi cant relationships with intended action.
For example, the category means on social restrictiveness, again for the nearest distance
zone, show those who would consider moving as holding the most socially restrictive
attitudes, followed by those intending individual action, group action, and no action—the
exact reverse of the ordering observed for the CMHI scale.

A nal analysis of variance was performed to test the relationships between the four
attitude scales and attitudes toward existing facilities. The respondents who were aware of
a facility (n = 132) were classi ed into three groups: in favor of (n = 95); indi erent toward
(n = 19); and opposed to ( n =18). Mean scores on each of the attitude scales were
signi cantly di erent for the three groups (table 10). Relationships are again strongest for
CMHI followed by social restrictiveness, benevolence, and authoritarianism. For CMHI and
benevolence, the highest mean scores are for the “in favor” group, and the lowest means
are for the “opposed” group. The reverse holds for the authoritarianism and social
restrictiveness scales.

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The strength, direction, and consistency of the relationships between the attitude scales
and the di erent measures of response to hypothetical and existing mental health
facilities provide strong evidence for the predictive validity of all four scales. For each of
the response variables, the strongest validation occurs for the CMHI scale—a nding that is
to be expected, and indeed hoped for, given the explicit community emphasis of this
dimension of attitudes toward the mentally ill. Similarly, the repeated emergence of social
restrictiveness as the second most powerful predictor is consistent with the content domain
for that scale, which emphasizes the potential dangerousness of the mentally ill and the
importance of maintaining social distance from them. The weaker predictive power for the
benevolence scale, most apparent for the relationships with intended opposition to
facilities, suggests a transcendent sympathetic attitude toward the mentally ill, which
conceals important attitudinal variations exposed by the other scales. Taken together,
these results are very encouraging not only in terms of scale validation but also in terms of
their potential usefulness in future studies of community attitudes toward the mentally ill
and mental health facilities.

Conclusions

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In the Toronto study, the development of scales to measure community attitudes toward
the mentally ill originated in the geographic problem of explaining spatial variations in
public response to mental health facilities. Four existing scales were the basis for
constructing a new set of scales representing the following four dimensions of community
attitudes: authoritarianism, benevolence, social restrictiveness, and community mental health
ideology. These scales di er from the originals in two main respects: rst, by their
emphasis on those facets of the content domain of each scale that relate most directly to
community contact with the mentally ill; and second, by the statements’ being worded with
a general public rather than professional sample in mind.

The internal and external validity of the CAMI scales was extensively analyzed using both
the pretest and nal data sets for the Toronto study. Weak items identi ed in the pretest
were replaced before the major data collection phase. High levels of internal validity were
shown for the nal scales based on item-scale correlations, alpha coe cients, and factor
analysis. External validity was examined in two ways within the theoretical framework for
the Toronto study. Construct validity was assessed by analyzing relationships between the
attitude scales and a range of personal characteristics. Predictive validity was tested by
analyzing relationships between the scales and various measures of response to mental
health facilities. In both cases, the strength, direction, and consistency of the relationships
provided strong support for the external validity of the CAMI scales.

The theoretical and practical signi cance of the CAMI scales is well demonstrated in the
Toronto study where these measures of attitudes toward the mentally ill are basic to the
explanation and prediction of individual and community responses to mental health
facilities (Dear and Taylor 1979). It remains for future studies to establish the applicability
of the CAMI scales beyond the Toronto situation, although there is no a priori basis for
questioning their generalizability.

The Toronto study is cross-sectional and provides no basis for establishing how sensitive
the scales might be as indices of attitude change. It is planned to use the same scales in a
study of community attitudes before and after the opening of a neighborhood mental
health facility. This will introduce a longitudinal dimension whereby changes in attitude
can be monitored and the usefulness of the scales for monitoring changes can be
established.

The Toronto data provide only a limited basis for analyzing attitude-behavior relationships.
As reported here, the scales are strongly related to behavioral intentions; the link with
actual behavior remains uncertain, since so few of the Toronto respondents had actually
taken any action to oppose a mental health facility. A focus for a future study is therefore
to examine the predictive validity of the scales for actual behavior with respect to both the
mentally ill and the mental health facilities.

The shift to community based mental health care emphasizes the need for reliable and
valid methods for measuring public attitudes toward the mentally ill. The CAMI scales

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discussed in this article represent an attempt to develop such a method, and it is hoped
that use of the scales in subsequent studies will further establish their validity. [1]

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Acknowledgment
The research reported was supported by Grant No. 410-77-0322 of the Social Science and
Humanities Research Council of Canada.

The Authors
Dr. S.M. Taylor holds a Ph.D. in geography from the University of British Columbia, and Dr.
M.J. Dear, a Ph.D. in regional science from the University of Pennsylvania. Both are
presently Associate Professors in the Department of Geography at McMaster University in
Hamilton, Ontario, Canada.

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

[1] Copies of the statements are available on request from the authors.

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