the nature and correlates of community mental health ideology in community mental health centers

THE: SATUKE AND CORRELATES OF COMhlUNITY SIENTAL HEALTH IDEOLOGY I N COMMUNITY

MENTAL HEALTH CENTERS* STANLEY S . ROBIN AND 31ORTON 0. WAGENFELI)

Wester/( Michigun lliiiuersily

Five hundred ninety-five staff :it 20 CJIHCs were surveyed as part o f a large study o f mental health worker roles. Uata on the endorsement of the ideology o f community mental health (CMHI) were obtained. Significant associations were found between ideology and level o f education and t.ime allocated t o I )irec.t tind Indirect Services. ]Afferent patterns were noted when specific.

I I(:CU at ions were considered. Significant nssociations were also found between ( ’Mi1 and orgttnieational and personal role and role discrepancy. Si nificant increments in the variance associated with CMHI were accountef for by personal role definition and time spent in Direct and Indirect Services. The absolute level of CMHI among staff was not high. The extent to which CMHCs are carrying out the ideology and the implications of this for the future o f the movement is questioned.

The intercst of sociologists in the study o f ideology has had a venerable history. This interest, though, has largely focused on various political ideologies or ideologies associated with social movements. More generally, Geertz (1964) has argued that ideologies function . . . to render otherwise incomprehensible situations mean- ingful, t C J so construe them as to make it possible to act purposefully within them.’’ Or, as John SIarx (1969) has indicated, ideologies represent shared cultural meanings that enable purposeful social action in the face of uncertainty. Increasingly, the shift i n the study of ideologies has moved away from the political arena to the professions. For the professional, an ideology is a guide for conduct or action in the face of an uncertain or incomplete command of reality. Marx has made the important observation that the significance of ideologies in a professional arena is inversely related to the extent to which the content of the field and the problems facing its practitioners have been completely understood. With the achievement of complete understanding, competing ideologies are replaced by agreement on principles and programs of action or procedures for dealing with situations. Ad- ditionally, he has suggested that three criteria apply to fields that are likely to generate ideologies: (1) newness or rapid expansion; (2) a premium on a particular- istic, subjective, or intuitive approach to the application of knowledge; and (3) a moral or ethical aura surrounding the subject matter.

Because of a paucity of knowledge concerning the etiology of mental disorders, ideology has been a particularly potent motive force in psychiatry and allied mental health professions (e.g., Hollingshead and Redlich, 1958; Strauss, Schatzman, Bucher, Erlich, & Sabshin, 1964; Armor & Klerman, 1968; Wagenfeld, 1972). The latest of these ideologies is that of community mental health. It arose, in part, as a reaction to the failure of the traditional mental health care delivery system. Adequate mental health care was the province of the affluent, while the poor were relegated to stat(. mental hospitals where they received custodial care.

*Based on a aper iesented t o the Annua1,Meeting of the N y t h Central Sociolo ‘cnl Aseocia- tion, Columbus, f;hio, #lay 1975. This pa er IY part of a stud Emerging Roles oaCommunity Mental Health Workers,” funded by Grant &HI8958 from the d t i o n a l Institute of Mental Health.

33.5

336 STANLEY s. H O I ~ I S A K D iioiwox 0. IVAGESFELL)

The ideology was actualized as a result of President Kennedy’s call for a “bold new approach‘’ to the care and treatment of the mentally ill and the consequent passage by the Congress of legislation to establish a new form of mental health care delivery system : the Community Mental Health Center (CMHC). The intent of the legislation was the establishment of a national network of these organizations to adequately serve all strata in society. While traditional mental health systems had been geared largely to secondary and tertiary prevention (early detection and treatment of disorder and rehabilitation), CMHCs would go one step further and put “community” into the delivery of mental health services via primary prevention: a lowering of the rate of new cases of mental disorder through an alteration of various features of the social structure thought to be inimical to mental health (Caplan, 1964). In order to achieve these ends, federally funded CPIIHCs were mandated to provide five essential services : Inpatient, Outpatient, Emergency, Partial Hospitalization, and Consultation and Education. The movement achieved a remarkable rate of growth in the 1960s. More than 540 CMHCs have been funded and 400 are in operation (NIMH, 1973).

Baker and Schulberg (1967), in developing a scale to measure the ideology of community mental health, noted that it consisted of five conceptual dimensions: Continuity of Care, Population Focus, Primary Prevention, Social Treatment Goals, and Total Community Involvement.’

The adoption of the community mental health ideology by community mental health workers, however, is far from uniform. Baker and Schulberg (1967) first noted considerable variation in ideology endorsement among the members of the various disciplines involved in community mental health. Later research by Wagenfeld, Robin, & Jones, (1974) showed that the level of ideology varied by specific CMHC and several organizational characteristics of the centers. Strongest endorsement of CMHI was associated with workers at centers under University and Agency/Board auspices, and for workers serving rural catchment areas. The research also replicated the earlier findings that ideology was associated with worker’s discipline : the medical personnel and paraprofessionals low in ideology and social workers and psychologists relatively high (also see Wagenfeld & Robin, in press). CMHI was also highest when workers perceived their centers as organized on a social agency rather than medical model basis.

Further understanding of the correlates of CMHI endorsement is needed to assess the nature of the ideology in centers. With the establishment of community mental health centers, the guardianship of the ideology passed from the theorists to the community mental health workers. It was the workers in community mental health centers-as members of their centers-who were to put this ideology to use; the continued existence of this ideology and its ultimate form, therefore, depends strongly upon the circumstances under which it is conceived, endorsed, and used

‘More specifically, Population Focus was defined a‘: “The mental health specialist should be responsible not only for the patient in contact but also for the entirerpulation of the community.” Primary Prevention was: “The ratc 2f mental disorder can be lowere by our counteracting harmful forces.” Social Treatment Goals: The iimary a m of treatment is not to reconstruct the per- sonality but rather to help the patient acgeve social adjustment.” Comprehensive Continuity of Care: “There should be a continuity in professional respoils,i$dity to provide an integrated network o f care-giving service.” Mental Health Specialists can extend their effectiveness by working with and throtgh other pcoplc.” These conceptual dimensions are not used to generate subscale scores by Baker and Srhulberg; we also used a total scale scorc.

Total Conimnnity Involvement :

by workers in t,hr center. This research c.oiitiiiues thc investigation of CMHI by focusing upon the relationship of CAZHI to t.hree quite different sorts of factors. First, IVC are concerned 1vit.h relationship hetween CMHI and two factors tha t may logically ;iffc.ct the socializat’ion o f thv \vork(.r to the ideology: age of the worker snd workw’s lcvc4 of education. The :tgc of the worker is indicative of the time at \vhich hc recoiwd his professional socialization in relation to the development and implementation o f the ideology. The ivorker’s level of education is indicative of the extent of 1)rofessional socialization which niay include, support, or be antithetical t o coinniunity mental health ideology.

The second set, of factors deals with the effect, of center eniploynierit and experiencc upori ideology. While the CSlHCs are intended as a reflection, embodi- ment, and repositorv (Jf this ideology, \vorker’s experiences within the center are far from homogeneous. Years a.t the center should be associated with ideology endorsement, sincca it describes the length o f the socialization process in an organization. The servicv or component of t’he center in which the worker invests his professional activit\. should be associated with ivorker ideology. Direct service provided by the center approximates most closely those activities contained in the more traditional niodalities of mental health services. Indirect services, on t’he other hand, involve consult,ation with the community, community education, and a variet,!. of activities consistent with the ideas o f primary prevention and social change agentrJ-. Ideology should be associated with the proportion of worker time spent ill direct and indirect servicw. Since workers have other duties not confined to these, categories, they are not reciprocal and will be treated separately.

Dimensions of role constitute the third set of factors to be associated with CMHI. This is of central importanct:, since it provides one perspective on the translatioil o f abstract ideology into expected professional behaviors. Here we are concerned with three aspects of the \\-orker role: the extent of activism in the role defined as propcr from the worker’s perceptions of his community mental health center (CMHC .lctivism), the extent of activism in the role defined as proper from the worker’s personal/professional perspective without regard to organizationul constraint (I’ersonal/l’rcifession~l Activism), and the difference between the t \ v o which is labeled ‘‘role discrepancy.” In this analysis the extent of role activisni associated with CMHI is explored. Since role activism and CMHI are logically congruent, :L strong association should be expected if ideology is trans- lated iiito behavioral expectations in a direct an,d unfettered fashion. Suspecting that organizational constraints, based on extra-ideological factors may operate in this sphere, role activism is measured independently from the CMHC and personall professional perspectives. Role discrepancy-the difference between the two dimensions of role measured for each respondent-has a theoretical and empirical utility in its own right. Role discrepancy may be imperfectly related to either sort of role activisni. For example, it is possible for a worker to indicate a moderate level of personal/professional activism and a very low CMHC activism, resulting in relatively hityh role discrepancy. It is also possible for a worker to indicate very high personal/professiorial act,ivism and very high CMHC activism, resulting in low role discrepancy. Thus, an independent investigation of role discrepancy and the endorsement of CMHI is appropriate. Thc endorsement of ideology in the face o f rolc discrepancy ma!. hc t hreatenirig for the worker, inhibiting ideological

338 STANLEY S. ROBIN AND MORTON 0. WAGENFELD

endorsement; or it may constitute an act of rebellion, leaving unaffected or even enhancing CMHI endorsement. Therefore, if discrepancy is found among workers in centers, its relationship to CMHI is important in ascertaining the nature of the ideology as it exists in CMHCs.

METHOD This article is drawn from a larger study. The objective of the larger study

was an examination of community mental health worker roles. Community mental health workers were defined as professional and paraprofessional staff employed by community mental health centers. In order to obtain a sample of workers, 20 CMHCs were selected for the research as representative of the major catchment area and organizational characteristics of operating centers. The sample of centers also represent all geographic areas of the United States, being located in 16 states ranging from Maine to Florida, and New York to California. The sample of centers also represent a wide variation in staff size, from a low of 16 to a high of 377.

Questionnaires were developed and mailed to all appropriate staff in the 20 centers in accordance with mailed questionnaire methods developed by Robin (1965) and Glock and Stark (1966). Staff were identified by name and professional affiliation on rosters submitted by center directors. Useable questionnaires were returned by 55.8% of all staff.*

The dependent variable, community mental health ideology, was measured with the BakerSchulberg Community Mental Health Ideology Scale. This scale consists of 38 items scored on a seven-point Likert Scale. High scores indicate a strong adherence to community mental health ideology. As reported by Baker- Schulberg (1967), the scale was found to have a corrected split-half reliability coefficient of .95, a Cronbach Alpha (Kuder-Richardson Formula 20) of .94, and a test-retest reliability of .92.3

The variables, age, years a t center, percent of time spent in direct services, and percent of time spent in indirect services, were reported by the respondents. Respondents’ level of education was self-reported and subjected to reliability cross- checks within the questionnaire.

Community Mental Health Center Role Activism was calculated by presenting each worker with a set of 18 community mental health vignettes illustrative of “typical” community situations they might encounter. To each vignette, the worker was asked to indicate which of a series of four role behaviors he/she felt the CMHC expected of him/her as a worker. The behaviors presented to the respondent were systematically varied in the extent to which they are activist. In other words, responses ranged from “traditional” activities such as consultation with caregivers or the giving of expert testimony to such “nontraditional” behaviors as helping to organize and participate in sit-ins, strikes, etc. Activism was seen

ZAnalysis of nonrespondents by professional affiliation did not reveal any large scale anomalies. However, differential response rates were observed when controlling for certain categorizing variables and should be observed when interpreting the findings of this research. Centers with inner city catchment areas are underrepresented in the responses. The Centers which were governed locally and those with agency/board governance are sllghtly underrepresented. Centers comprising one agency or over seven agencies are also underrepresented In response rates.

*This summated measure has been used in several studies and is well validated (Baker & Schul- berg, 1967; Howard & Baker, 1971; Langston, 1970; Wagenfeld et al., 1974).

N.iTUHE .491) CORRELATES OF CO.\IMIJSITY MENTAL HEALTH IDEOLOGY 339

as the nillingness to change the conmiunities or social structures as a solution to the mental health problem presented in the vignette. Each set of substantive responses were ranged from 1 (least activist) to 4 (most activist). The sum of the scores over the 18 vignettes served as the activism score.

Personal/ Professional Role Activism was measured in exactly the same fashion except that the respondent was asked to select the preferred role behavior on the basis of his/ her personal and professional preference. Role Discrepancy is the arithmetic. diff erence in activism scores between the workers view of the center’s role expectation and that workers persoria1,lprofessional role expectation.

RESULTS The respondents from our national sample had a mean CMHI score of 212.44.

Compared to the potential range of 38 to 266, the scores are indicative of a fairly strong endorsement of a community mental health ideology. When aggregated in the various ways for our subsequent analysis, the means ranged from 186.7 for psychiatrists engaged in indirect services for less than 10% of their time to 234.5 for social workers engaged in indirect services for more than 25y0 of their time. The raiige o f scores, howevrr, is relatively modest when compared to the mean scores of the nine criterion groups used by Baker and Schulberg (1967) in the initial development of the CMHI (194.2 to 239.79). Of importance here is that the Bakrr and Schulberg criterion groups were not employed in CMHCs, while our sample was. Our sample’s mdorsement of CAMHI does not reveal CMHCs as bastions of Cl IHI .4

I t was suggested that adherence to the ideology of community mental health would be related to characteristics of the worker and his organizational experience. In addition, we posited a linkage between ideology and its actualization as perceived organizational and personal/professional role and the discrepancy between the two.

The first characteristic to be considered is age of the worker.5 No significant relationship existed between age and ideological endorsement. In considering level of education and its relationship t o ideology, one cannot examine i t for the total sample ; there was too much heterogeneity of professional affiliation. Con- sequently, the relationship was examined separately for each of the major professional groupings i n the CMHCs for which one could expect variations in level of education : viz., psychologists, nurses, social workers, and paraprofessionals. Levels of education was significant1 y associated with ideological endorsement in only two groups: social workers and nurses. In both cases, higher levels of education were related to higher endorsement of ideology.

‘It is important to note that the lower potential range of the CMHI far exceeds the actual ran e of scores found in research in which the score is employed. While data c:ollected using t,he CMIh have produced scores approaching the up er level of. the potential range, data from quite diverse samples indicate that the lower quartile or the range IS not used. The lowest individual score from one sample of community health workers in 20 centers was 83 (Wagenfeld et al., 1974), from a second sample of workers in t.wo centers waa 129 (Lan ton, 1970), from criterion groups, 92 (Baker & Schulberg, 1967), from Community Mental Healtf Center Board members, 157 (Baker & Schulberg, 1969), from paraprofessionals in centers, 108 (Poovathumkal, 1973) and from spchologista in centers, 174 (Block, 1974). The meaning of mean differences between groups in CMHfscores and the absolute interpretation of the scores, therefore, must be made noting this characteristic of the CMHI scale.

sTables displaying t.he relationship betwecw thc independent variables and the CMHI are available from t h r authois o i i request


Moving to variables that can be more directly related to the CMHC, we can consider number of years at the Center and degree of community contact of the worker as they relate to ideological endorsement. The data indicated quite clearly that length of employment and ideological adherence were quite independent. In an earlier paper (Wagenfeld et al., 1974), we suggested that the discipline of the worker, rather than his/her CMHC was the more salient source of ideological socialization. This finding would seem to strengthen the prior observation.

We hypothesized that degree of involvement with the community (through the provision of Indirect Services subsumed under the general heading of Consulta- tion and Education) would be directly related to degree of ideological endorsement. By the same reasoning, we thought that extent of involvement with Direct Services to clients or patients would be inversely related to ideological endorsement. In asking our respondents to list the proportion of time that they allocated to both of these activities, we were able to obtain direct measures of the variables.

Almost 90% of our respondents (531 of 595) provided some direct service to patients or clients. In fact, a majority (75.3%) spent a t least one-quarter of their time in this area. Given this, it is interesting to note that the degree of ideological adherence decreased significantly and in a near linear fashion with amount of direct patient care involvement. The CMHI mean for those with no time in Direct Services was 219.6, decreasing to 208.2 and 203.4, respectively, for those spending between one-half to three-quarters and three-quarters to all of their time in this type of service. With this support of the hypothesis for the sample as a whole, a next logical question was whether the same situation obtained with respect to the major occupational groupings within the ChlHC : psychiatrists, psychologists, social workers, nurses, and paraprofessionals. Given the unequal distribution of time allocated to Direct Services and the smaller ns for our specific occupations, we dichotomized amount of time spent in this activity as equal to or less than 25% and more than 25%. This analysis by occupation indicated higher means in each disciplinary group for those spending more than 25% of their time in Direct Services. Statistical significance between those spending less than and more than 25% of their time in Direct Services was achieved for three of the five groups: psychiatrists, social workers, and paraprofessionals. It is interesting to note further that the magnitude of ideological adherence did not seem to be associated with provision of Direct Service ; psychiatrists and paraprofessionals-low on ideology-showed significant decrements in ideology with increasing patient contact. Social workers- ideological “leaders”-also showed the same pattern.

Perhaps the most direct application of LLcommunity” to community mental health is amount of time in Indirect Services. In this activity, the worker does not treat patients but, instead, engages in a variety of consultative and educational activities with community caregivers (e.g., clergy, police, teachers) to increase their understanding of mental health problems and to make them more effective within their own respective disciplines. Additionally, Indirect Service can include community organization and development.

An examination of Indirect Services revealed several things. First, the provision of Indirect Services was less common than with Direct Services. About 90% of the respondents were concerned with the provision of some Direct Services; in contrast, about 80% were allocating some part of their time to Indirect Services.

NATURE A S D CORREL.4TES OF COMM I - S I T Y MENTAL HEALTH IDEOLOGY 341

Also, the very skewed nature of the distribution of time for this activity is evident: a minority of the staff (28%) spent one-quarter or more of their time in these community-based enterprises while, in contrast, a majority of the staff (75%) spent one-quarter or more of their time in Direct Services.

Of more direct concern, our hypothesis relating ideology and Indirect Services was confirmed at a high level of statistical significance ( p > .O001) and in the expected direction : increasing involvement with t,he community was strongly associated with greater adherence to the ideology of community mental health. With increasing time in Indirect Services t,here was a linear increase in ideology, and a linear decrease in standa.rd deviation, suggesting that CMHC workers involved in the community were considerably more homogeneous in their beliefs than t,hose working “within the walls” of the Center.

Following the logic employed in the analysis of ideology and Direct Services, we examined ideology and Indirect Services for the major occupational groups in the CMHC. For all disciplines, there was greater CMHI endorsement among those more involved in Indirect Services. Again, statistically significant differences were obtained for psychiatrists, social workers, and paraprofessionals.

Our earlier work (Wagenfeld, Robin, &: Jones, 1974) suggested that certain characteristics of the organization and catchment area were predictive of ideological adherence (e. g., :tuspices and nature of the catchment area). Carrying the analysis further, we are suggesting that adherence to or endorsement of the ideology of communit,y mental health is significantly related to degree of contact with the community : the greater the amount of time involved in community-based activity, the greater t>he liklihood of endorsing thc CMHI.

I t was suggested earlicr that if perceived role in a particular situation was simply an elaboration and specification of a more abstractly held ideology, then the two ought to be highly correlated. Wa argued further, though, that one might perceive one’s organization as a constraining or conservatizing force and, so, organizational rolcl might differ from personal o r professional role. The net result would be role discrepancj. which, in itself. might be related to degree of ideological adherencv. TABLE 1 . Pt;.\HSOS P R O D U C T - M O M E N T ~ ~ W ~ I A T I ~ JNS BKTWPXN C O M M U N I T Y MKNTAL HEALTH

1Dt:OLOGY AND PERCI..IVI~:U R O L E VARIABLE3 ._ - ~~ ~-

ChlHI CMHC P P Role Category 1Vf S 1 ) Activism Activlvrn Discrepancy

~~

Total Sample 212 4 27 !I I9* :37* - .18* ( n = 595)

Psychiatrists ( n = 72)

194.8 31 0 35* :%I* - 10

Psychologists 218.8 2 3 . 2 .05 1 3 - .09 ( T I = 96)

Social Workers 220. !) 26 4 20* 37* - .16* (n. = 140)

(.?a = 95) Paraprofesionals 207 4 26 2 .17* 26, - .07

Nurses 210 2 28 s .31* 53 * - .28* (71 = 96 j

*Statistically sigriifiwnt : i t iir‘ heyrrntl the .05 level for a one-tailed test.


Table 1 indicates quite clearly that ideology and the several specifications of role exhibit a very wide range of association. It can be seen that for the entire sample and for the occupational subsamples, there was a higher degree of association between CMHI and Personal/Professional perceptions of role than between ideology and perceptions of organizationally expected role. Also, the magnitude of the correlations varied a great deal by discipline. When we compared the average level of ideological endorsement for the entire group and for the subsamples with the ideology/role correlations, no clear-cut pattern emerged. Relatively high degrees of association between ideology and both organizational and personal role were found for occupational groupings with widely varying levels of ideological endorsement (psychiatrists, social workers, and nurses). In contrast, for psychologists, with a stong ideological adherence, the association with the role variables was rather small. The same situation existed with respect to role discrepancy.

The next step in the analysis was to move from consideration of single variable relationships with ideology to a more comprehensive, multivariate approach. Since all of the variables-with the exception of level of education and professional affiliation-were continuous, a stepwise multiple regression analysis was used. TABLE 2. PEARSON PRODUCFMOMENT CORREL.\TTIONS OF CVMMUNITY MENT.4L HEALTH IDEOLOGY

AND ORQANIZATIONAL .\ND PERSONAL VARIABLES (12 = 595)

Years at Direct Indirect CMHC P/P Role

CMHC Age Services Services ChlHI Activism Activlsm Discrepancy

Years at CMHC .40* -.12* - . 0 4 .OO .07 - 08 .14* Age of Worker -.07 - . 08 .01 .06 - . l o * .14*

Time Spent: Direct Services

Time Spent : Indirect Services

Community Mental Health Ideology

CMHC Activism Personal/ProfessianaI

Role Discrepancy Activism

- .48* -.2ri* b . 0 8 - .12* .03

.20* .04 .11* - . 0 5

19: .37* - . I t % * 46* .48*

- .56*

*Significant at or beyond .0.5 level using one-tailed test

Table 2 presents the zero-order intercorrelations of the several variables under investigation. Inspection of the table shows statistically significant associations among CMHI and Direct and Indirect Services and the three role measures. Not unexpectedly, the three role measures were significantly intercorrelated with one another. However, they showed considerable independence : the prediction of one role measure by another ranged from 21 to 30%. Parenthetically, i t might be noted that while CMHI was totally unrelated to length of employment and age of the worker, significant associations were noted between these two and role discrepancy: the older the worker or the greater the length of service a t the CMHC, the lower the amount of discrepancy.fi

aworiation indicates nn inverse relationship. ‘It should be noted that since discrepancy ww drnost idways in a negative direction, a positive

SATCRE .4ND CORRELATES OF’ CO\lJlIJNITY MENTAL HEALTH IDEOLOGY 343

TABLE 3. STICPWISI: MULTIPLE KEGRF;SSION OF COMMUNITY MENTAL HI~XLTH IDEOLOGY .AND ORGANIZATIONAL . \ N D P E R S O N A L V A R I A B L E S

- ~~~~ ~

Variable Increase

I? I P F P in H

Personal/Professiori2tl - Activism :Itis 1 :I.-) 92 8 < oooo1

Time Spent in Ilirect Service> 422 17!( 31 4 < ooool 054

Time Spent in Indirect Serviw. 490 1% 4 1 3 < 0 4 008

Age of Worker 432 I X i 42 > 05 002 Itole Discrepancl 433 I hh 1 .i > O.i 00 1 Years at CMH(’ 438 I hX Oti > 03 OOO CMHC Activlmr 433 1 xx 002 > 03 OOO

Final K = .4 ;U F = 15.0. p < .O(M)Ol

The multivariate approach of stepwise multiple regression with CMHI as the dependent variable is presented in Table 3. Personal/Professional Activism provided the single greatest predictor of the variance in ideology. Only two variables added significant increments to the shared variance with ideology : Time Spent in Direct Services, and Time Spent in Indirect Services. It is interesting to note that two of the specifications of rolc-personal and organizational-represented the extremes in explanatory power. The link between ideology and role w&s most manifest on the personal side of the ledger, and least so on the organizational. These three variables-Personal/Professional Activism, Time Spent in Direct Services, and Time Spent in Indirect Services-accounted for almost 19% of the variance in the endorsement of community mental health ideology.

DISCUSSIOX This articlebuilding on our earlier research on the correlates of adherence

to the ideology of community mental health-explored three areas. First, we were concerned with personal characteristics of the community mental health worker that might have a bearing on ideological socialization (i.e., age and level of education). Next, we hypothesized that organizational experiences (years at CMHC, degree of contact with the community, time spent in direct patient services) would relate to ideological endorsement. Finally, we explored the relationship between ideology and several dimensions of perceived role, hypothesizing that the relationship was not a simple, direct one.

The first of our two “socialization” variables-age of the worker-was not significantly related to CMHI. The other variable-level of education-proved to be more of a mixed bag. Higher levels of education were significantly associated with greater ideological endorsement for only two of our four subsamples: social workers and nurses. For social workers, the professional-level entry degree is the MSW. The holders of this degree have, of course, experienced a two-year process of socialization to the profession in graduate school. In a similar vein, the cutting point for nurses was Baccalaureate degree. Again, with increasing professional- ization within nursing, t hc Bachelor’s degrce is becoming more normative. We


may speculate further that the nurse with a t least a B.A. has undergone a different process of socialization than her counterpart with an RN or LPN, uiz., training and general education in a setting other than the epitome of the medical model institution-the hospital.

For psychologists, it seems reasonable to speculate that, even though the Ph.D. or equivalent is considered to be the professional degree for many positions, the dichotomy is not as sharp as it is for social workers. Additional training in psychology does not carry with it an increment in socialization to the ideology of community mental health. It should also be borne in mind that the overall level of ideology of psychologists is high to begin with. What we are suggesting is that significant increments in adherence to the ideology of community mental health are related to average level of ideology for that group and the attainment of some professional level degree. For the paraprofessionals, the very lack of consensus on a definition of the category as a distinct entity and the attendent heterogeneity of socialization may preclude the emergence of clear ideological patterns.

Moving to the “organizational experiences” variables, we could find no association between length of time a t the CMHC and any change in level of ideology. This strengthens our earlier observation (Wagenfeld et al. , 1974) that the socialization experiences associated with different occupations or professions are more powerful sources of ideological endorsement than the CRlHC itself. More specifically, length of time a t the CRIHC, per se, does not appear to be a socializing of de- socializing factor insofar as the holding of an ideology. The next two variables considered under the heading of “organizational experiences” suggest quite clearly that the internal characteristics of the CMHC are not devoid of structural variations in adherence to CMHI. Amount of time spent in direct patient care and amount of time spent in the community providing indirect services were both strongly associated with ideological endorsement, albeit in opposite directions. The more time one spends in direct services, the lower the level of ideology; and the more time spent in the community, the greater the level of ideological endorsement. When broken down by major professional groups, a somewhat heterogeneous pic- ture-akin to that found with edueation-appeared. Significant differences were found for psychiatrists, paraprofessionals, and social workers. These groups vary markedly in endorsement of CMHI, so a simple explanation is not immediately evident. One could argue that the medical training of psychiatrists is antithetical to the development of a community orientation, but that actual exposure to the community via indirect services may sensitize thein to the existence of etiological factors “out there” and, thus, to greater endorsement of the CMHI. That does not, however, explain why the same relationship with respect to nurses-another medical group-did not achieve statistical significance. Perhaps what we have observed is a reflection of differential status or prestige. The status and prestige conferred upon psychiatrists by the MD may give them a greater latitude for change than that accorded to nurses. Additionally, statistically significant differences were found with a “high ideology” group (social workers), but not with a group (psychologists) that endorsed it in an equally strong manner.

The convergence of role variables and ideology seems of considerable importance. From one perspective it can be seen as the translation of abstract ideology into relatively concrete role specifications. While all the role variables, Personal /

Y.4TITRF, .4YD (’ORRELATES OF CO>IVI’XITY M E N T A L HEALTH IDEOLOGY 345

Professional Activism, CJIHC Activisni, and Role Discrepancy are significantly correlated with CMHI, the highest of these, Personal/Professional Activism shows only 14y0 of the variance with CMHI. Clearly in this area the step from ideology to behavioral prescription is a long and uncertain one.

When broken down by discipline, some clues to the nature of the relationship are evident. Psychiatrists, with a low level of activism, both CMHC and Personal/ Professional, translate this into role activism with the greatest fidelity and their relatively high ability to realize ideology in role may be a function of their “in- sulation by status.” They are relatively immune from other influences in this relationship by power and status. A similar situation obtains for nurses. Social workers, highest in CMHI, show a fairly high correlation between activism and CMHI, while psychologists, also high in CAIHI, do not. The professional socialization of these two groups is quite different, however . One speculation might be that, given the community orientation o f social workers, they have a stronger disciplinary socialization in both relevant role (to CMHCs) and ideology simultane- ously, while the psychologist, clinically trained, must fashion his CMHW role through post-professional training to a greater extent Thus the convergence of role and ideology is a weaker, less certain, outcome.

In our final analysis, we note that the best predictor of ideology is Personal/ Professional Role Activism with small but significant increments added by the type of center service the worker engages in. Hence, ideology is related to role definition and the arena in which the role is realized. Role discrepancy, years at center, CMHC role activism, age. etc. do not add to the prediction nf ideology. The age of worker, and, by inference, the relationship between time of professional socialization and development of ideology, provides no prediction of CMHI. Even though CMHI was largely developed in the 196Os, apparently the ideology is absent or ineffective in the socialization of those trained during the 1960s and earlv 70s. Adherence to this ideologj i h developed through other means. The same conclusion can be arrived at by noting the lack of prediction o f CMHI by years at the CMHC. But this nonsignificant relationship also tells us that the centers are not effective socializers to the ideology. This in turn is buttressed by the lack of relationship between CMHI and CMHC activism and role discrepancy. I t does not matter for the endorsing of the ideology what the perception of the center-defined role is or what extent of divergence exists between that perceived role and personal/professional role. If the center fails to socialize the wnrker for or against the ideology through general contact (time a t the center), it also fails to socialize though the specification of the worker role as perceived by the worker. Ideology is thus selectively related to personal/professional role and experiential factors suggesting that the development and maintenance of ideology is a process not uniformly or generally accomplish- ed in an environment formally designed to foster and exercise that ideology.

Since the level of ideology for the worker in the center does not exceed the level of ideology found in those, in the same disciplines, outside the center, we may question the centers’ functioning as a repository, exemplar, and purveyor of the ideology. The “bold new approach to mental health” may not have been realized in the form of ClIHCs. This makes excellent sense; if the centers are not repositories of the ideology, it is unlikely that they will be effective socializers to the ideology, pxrept inridmt:ill\. ac: :I function nf the type of work assigned tn the CMH worker.


The factors associated with CMHI only account for 19% of the variance of the ideology. It is not unreasonable to assume that more potent factors exist in the personal characteristics of mental helath workers, in the professional activities and settings external to the centers and in experiences prior to employment in the centers.

The Community Mental Health Centers appear to be staffed by workers heterogeneous in CMHI. Further experiences within the center have little or no significant association with the endorsement of the ideology. The question arises “to what extent can an organization so constituted pursue the purpose for which it was conceived?” If the centers are constituted of workers who are no more supportive of community mental health than their peers in other settings, who are diverse in their degree of endorsement and who are not subsequently socialized to the ideology, then the coherence of the CMHC as the realization of the movement, and as a new direction in mental health services must be questioned.

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the nature and correlates of community mental health ideology in community mental health centers

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