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British Journal of Psychiatry (1996), 168, 191-198

Community Knowledge of Mental Illness and Reaction 'to Mentally 111


People
GEOFFREY WOLFF, SOUMITRA PATHARE,TOM CRA1G and JULIAN LEFF
Background. We test the hypothesis that negative attitudes to mentally ill people may be fuelled by a lack of
knowledge.
Method. A census of knowledge of mental illness was conducted in two areas prior to the opening of long-stay
supported houses for the mentally ill in each area. Three attitudinal factors ( Fear and Exclusion, Social Control
and Goodwill) which had been extracted by factor analysis of the CommunityAttitudes toward the Mentally III
(CAMI) inventory (see previous paper) were analysed in respect of their associations with knowledge of mental
illness. Results. Most respondents (80%) knew of somebody who had a mental illness but a substantial proportion
of respondents had little knowledge about mental illness. Social Control showed an association with knowledge of
mental illness. Groups who showed more socially controlling attitudes (especially those over 50 years old, those of
lower social class, and those of non-Caucasian ethnic origin) had less knowledge about mental illness. Regression
analysis revealed that when knowledge was taken into account, age had no effect on Social Control, and the effect
of social class and ethnic origin was diminished. Respondents with children, who showed more Fear and
Exclusion, were not less knowledgeable about mental illness. Conclusions. The results support the hypothesis
that negative attitudes, especially in older people, are fuelled by a lack of knowledge. Negative attitudes among
people with children are not related to a lack of knowledge.The general public is coming into increasing contact
with the mentally ill with the shift towards community-based care in the UK. The community's attitudes towards the
mentally ill will have a major influence on the acceptance of the mentally ill and their social .integration. These
attitudes may be at least partly determined by knowledge about mental illness. This paper reports on community
knowledge about mental illness and reaction toward mentally ill people, prior to the opening of group homes in the
vicinity.

Method ,

Details of the survey, interviews and questionnaires are given in the previous paper (WolfT et al, this issue). Three factors had
been extracted by factor analysis of the Community Attitudes Toward Mental Illness Inventory (CAMI). These were labelled
Fear and Exclusion, Social Control and Goodwill. Fear and Exclusion included items such as "It is frightening to think of people
with mental problems living in residential neighbourhood". Social Control included items such as: "As soon as a person shows
signs of mental disturbance, he should be hospitalised". Goodwill included items such as: "We need to adopt a far more tolerant
attitude toward the mentally ill".
Statistical analysis
Analysis was carried out using SPSS (Norusis, 1988). Tests of relationship of attitudes to knowledge and behavioural intention
variables were carried out using a Student's <-test where the characteristic has two categories (e.g. belief about the intelligence of
the mentally ill) and using a one way A-NOVA where there were more than two categories (e.g. number of illnesses named).
Correlations were performed using Spearman's r. Analysis of relationships between categorical variables was carried out using ^ 2.
The effect sizes (the difference in means divided by the population standard deviation) were calculated for associations with Fear
and Exclusion, Social Control and Goodwill (see previous paper). Stepwise multiple regression was carried out on factor analysis
scores, sociodemo-graphic and knowledge variables.
Results
Two hundred and fifteen people were interviewed. Further details of the respondents are given in the previous paper.
Analysis; Student's t-test and one wayANOVA.
Knowledge of mental illness

Naming of mental illnesses


Twenty-one per cent of respondents couldn't name any types of mental illnesses; 19% could only name one and 60% could name
two or more. The mean number of correct mental illnesses ^cited was 2.1 (s.d,-L8).
/ Schizophrenia was by far the most commonly know.n-.type of JnentalJllness (74%). This was followed by depression (39'%),
manic-depression (19%) and paranoia (13%). It is noteHortby that some people cited Munchausen's syndrome by .proxy as a
mental illness as they had heard of this in the media in relation to the Beverley AUitt case. (In April 1993, Beverley Allitt was
found guilty of murdering four children, attempting to murder three and injuring six. She was~reported as having Munchausen's
syndrome by proxy (Dyer, 1993).) This, and other cases, may have accentuated some people's fears about the mentally ill being a
danger to their children (see previous paper).
Knowledge of mental handicap and its distinction from mental illness

Forty-six per cent of respondents were able to give the correct definition of mental handicap (a definition was deemed correct if
the respondent included some notion of low IQ, including "learning difficulties", or that it was both from birth and a permanent
state); 49% were able to give a correct example of mental handicap .(most cited Down's syndrome); and 52% were able J.O ,
distinguish correctly between mental illness and mental handicap. Only 25% of respondents, however, could do all three
correctly.
Belief that the mentally ill may be less intelligent
Most respondents (74%) thought that the mentally ill were no more or less intelligent than other respondents. A further 9%
thought they were less intelligent, 9% didn't know and 8% thought they were more intelligent. An example of a comment from a
respondent who believed the mentally ill were more intelligent is as follows: "They're more intelligent. Some of them like books
they study so much it overpowers them".

The association between knowledge of the mentally ill and Fear and Exclusion, Social Control and Goodwill

Respondents who could name one, two or .atJeast. three mental illnesses showed less Social Control than those who could not
name any (effect sizes 0.88, 1.18 and 1.55 respectively;^" <0.001). There was no. association with Feaf, and Exclusion or
Goodwill (Table 1).
Respondents who could correctly define mental handicap, give an example and distinguish it from mental illness showed less
Social Control (effect size =0.68) and more Goodwill (effect size =0.38). There was no association with Fear and Exclusion
(Table 1)
Respondents who thought that the mentally ill nay be less intelligent showed more Fear and Exclusion (effect size =0.36) and
more Social Control (effect size= 1.00). There was no associa-ion with Goodwill.
Social Control was associated with all three know-edge variables and effect sizes were large whereas 'Joodwill and Fear and
Exclusion were associated with )nly one and effect sizes were modest.
knowledge about mental illness in different ociodemographic groups

Groups which had shown independent associations see previous paper) with higher Fear and Exclusion those with children in
the household), higher Social control (lower social class, people of non-Cauca-ian ethnic origin (Africans, Asians and Carib>eans), people aged over 50, people who had lived onger on the street, people with children in the lousehold, and people who had
not suffered from a riental illness) or lower Goodwill (lower educational svel, Asians) were compared with the rest of the
espondents to determine^whether they were less inowledgeable
Respondents were less likely to be able to name at least two mental illnesses correctly if they were of lower social class, of
lower educational level, non-Caucasian, older or longstanding residents in the street. People who had not suffered from a mental
illness or who did not know anybody who had suffered from a mental illness were also less likely than other people to be able to
name at least two mental illnesses correctly. There was no difference in knowledge of names of mental illness in respondents with
or without children (Table 2).
Respondents were less likely to be able to define and give an example of mental handicap, and distinguish mental handicap
from mental illness, if they were of lower social class, of lower educational level, non-Caucasian or older. There was no
association with having children, having suffered from mental illness, knowing somebody who had suffered from a mental illness
or length of time in the street (Table 3).
Respondents were more likely to think that the mentally ill may be less intelligent if they were of lower social class, of lower
educational level, non-Caucasian, older or longstanding residents in the street. There was no difference in the belief that the
mentally ill may be less intelligent in respondents with or without children, those who had suffered from mental illness or knew
somebody who had suffered from a mental illness (Table 4).
Thus, all the groups with more negative attitudes, except those with children, showed lack of knowledge of mental illness on at
least one of the knowledge variables. Multiple regression analysis, however, ),eyealedthat knowledge variables had an
independenTeftect on Social Control only, and not on Fear and Exclusion or Goodwill.
In the previous paper, regression analysis showed that the contribution of various sociodemographic variables on Social
Control were as follows: social class (Beta =0.40, P= 0.001); ethnic origin (African:
Beta=0.27, J'>=0.001; Asian: Beta=0.19, P=0.00l;
Caribbean: Beta=0.18, /'=0.001); age (Beta=0.15, P=0.05); length of time in the street (Beta =0.20, P = 0.01) number of children
under the age of 18 in the household (Beta = 13, P=0.05); and having suffered from mental illness (Beta=0.13, P=0.05) (Multiple
J?=0.72, F= 24.01, d.f. =8, ^<0.001).
When knowledge variables such as the belief that the mentally ill may be less intelligent (Beta =0.15, P<0.01) and the number
of mental illnesses named (Beta = 0.12, P < 0.05) were introduced into the multiple regression analysis of sociodemographic
variables and Social Control, age no longer exerted an independent effect and the contribution of social class and ethnic origin
was reduced (social class (Beta=0.35, /'<0.001); ethnic origin (African:
Beta=0.22, P<O.Q5; Asian: Beta=0.15, P<O.Ql;
Caribbean; Beta=0.13, P= 0.001); length of time in the street (Beta =0.25, P< 0.001) number of children under the age of 18 in
the household (Beta =0.12, P=0.05); and having suffered from mental illness (Beta =0.12, P=0.05) (Multiple J?=0.74, F= 23.21,
d.f. =9, /'<0.001). The ability to define and give an example of mental handicap and distinguish mental
handicap from mental illness snowed no associations with any of the three attitude factors.
Identification of mental illness
* Most respondents (78%) thought they could tell if somebody was mentally ill. The most common
ways of telling were by strange, or odd behaviour (73%), odd speech (63%), the way they dress (32%), facial expression (25%)
and aggression (24%).
Causes of mental illness
The most commonly cited causes of mental illness were environmental (83%). Most respondents cited stress as the main cause.
They tended to break this down into relationship, family, work and financial problems and bereavement. Other causes cited
included heredity (39%), organic causes (22%), accidents (11%) and substance abuse (21%). Most respondents (73%) believed
that mental illness could be passed-down in families.
Where to get help

Most respondents (70%) said that they would contact a GP if a friend or neighbour was showing ^igns.of mental illness. Other
important contacts were: social worker (26%), hospital (24%), police (22%), the patient's family (22%), and one of the patient's
friends (14%). Africans and Caribbeans were twice as likely to say they would contact the police than others (36% v. 18%;
^=6.59; d.f. = 1; />=0.01). Women were more likely to contact the GP than men (75% v. 61%;
X2 = 4.67; d.f = 1; P = < 0.05). Respondents of a lower educational level (basic education) were more likely to contact a hospital
than those of a higher ('A' level and above) educational level (34% v. 18%; ^=6.39;
d.f.=l; P= <0.05). Respondents of a lower social class (III-V) were more likely to contact a hospital
than those of a higher (I & II) social class (34% v. 19%;
^= 5.28; d.f.=l;P=< 0.05).
Treatment of mental illness
Most respondents knew of drug treatment (75%) and psychotherapy (59%). Few respondents (12%) cited social treatments for
mental illness. Eighty per cent thought that mental illness could be controUed by treatment, 43% thought it co.uld cure mental
illness (Caribbeans were less likely to say that treatment cures mental illness than other groups (16% v. 48%; ^= 11.66; d.f. = 1;
= <0.001)) and 15% thought it made it worse,( often by over-sedating the patient and making them 'like a zombie'. Respondents

aged under 50 were more likely to say that treatment makes mental illness worse than those of aged 50 or over (17% v. 3%;
X2=11.69;d.f.=l;JO==<0.05).
Aggression and the mentally ill

A. significant proportion (43%) viewed the mentally ill as being more aggressive. A further 42% thought there was no difference,
13% didn't know and 2% thought they were less aggressive. It is noteworthy that the mean Fear and Exclusion score was similar
in the groups who thought they were more aggressive and those who didn't know. This is consistent with the hypothesis that there
is an element of'fear of the unknown' in people's responses toward the mentally ill. Respondents who felt that the mentally ill
may be more aggressive showed more Fear and Exclusion (effect size =0.63) and more Social Control (effect size =0.56) than
those who did not. There was no association with Goodwill. There was no association between any of the sociodemographic
variables and the belief that the mentally ill were more aggressive except educational level. Seventy-one per cent of respondents
of a lower educational level ('0' level and below) and 47% of higher educational level ('A' level and above) believed that the
mentally ill may be more aggressive (y1^ 11.36; d.f,= 1; P= <0.001).
Experience of mental illness
The majority of respondents (80%) knew of somebody who had had a mental illness; 30% of respondents said either themselves
or somebody in the family had suffered from mental illness; and 13% said they had suffered from a mental illness themselves.
There was an. association between knowing somebody with a mental illness or having suffered from a mental illness and less
Social Control (see previous paper).
Source of information about mental illness
Many respondents received most of their information about mental illness through personal experience of somebody with a
mental illness (33%) and through the media (32%). A further 10% acquired their information through friends and relatives and
26% from other sources such as from their academic studies or through their work.
Reaction toward the mentally ill
About two-thirds of respondents thought that other people would treat psychiatric patients negatively (usually by being wary or
avoiding them). A typical example is as follows: "(People would treat them differently), especially if children were involved.
Children would most probably be told to keep well away. People would point them out as those people being mentally ill. As
soon as that hostel over the road was built, everyone knew about it and everyone had their own views on it, some good but the
majority bad".
A significant minority of respondents (42%) said they, themselves, would treat a former psychiatric patient differently (or were
unsure or gave a qualified answer). Of those who said they would or might treat patients differently, most said they would treat
them in a negative way such as being wary of them: "Most probably deep down in the back of my mind I'd be frightened that
they might try and attack me if I said the wrong thing". Only a few said that they would make a positive effort: "I think I'd
probably go over the top to try and be normal. I'd probably make a real effort to say hello in the morning and that sort of thing."
The majority of respondents (60%) said they would have neighbours with psychiatric illness as friends and only 1% said they
would have, no contact with them at all. People who said they would have them as friends showed less Fear and Exclusion
(effect size =0.67; P= < 0.001) and more Goodwill (effect size =0.28; P= <0.05). Some respondents (23%) thought that they
might have problems with neighbours with psychiatric illness, 6% said it depends and 71% thought they would have no
problems. Most respondents (90%) said that they had no reservations about working with somebody who has had a mental
illness. There was an association between expressing reservations and more Fear and Exclusion (effect size =0.88;
P= <0.001). There was no association with sociodemographic characteristics such as having children.
Most respondents (87%) did not think that people were to blame for being mentally ill. There
was an association between expressing the view that they may be to blame and more Social Control (effect size = 1.23). NonCaucasians, respondents of a lower social class and those of a lower educational level were more likely to say that the mentally ill
were to blame for their illness. There was no association with age, having children, length of time in street, having suffered from
mental illness or knowing somebody who had suffered from a mental illness (table available from authors).
Respondents who thought that most people would object to ex-long-stay psychiatric patients living in the neighbourhood
showed more Fear and Exclusion (effect size=0.76; P= <0.001) than those who didn't. Only 9% said that they would object to
ex-long-stay psychiatric patients living in the neighbourhood and a further 18% had reserva tions. However, the vast majority
(73%) had no objections at all. Those who said they would or might object showed more Fear and Exclusion (effect size=D.97;
P=< 0.001). Respondents with children were over three times more likely to say that they would object to ex-long-stay
psychiatric patients living in the neighbourhood (17% v. 5%;
^= 12.86; d.f.=2; P= <0.01).
Mental illness came third (13%) in respondent's first choice of charity, behind sick children (43%) and cancer (38%). Diabetes
fared worst of all with only 5% of respondents ranking it first. Respondents who ranked mental illness first showed less Social
Control than the other groups (effect size =0.45; P= <0.05).
Discussion

The results show that most respondents have some knowledge of mental illness and that the majority knew of somebody who
had suffered mental illness. Indeed, our subjects showed greater understanding of the distinction between mental illness and
mental handicap than those studied by Reda (unpublished) who found that 35% could distinguish correctly. This may be
accounted for by the higher educational level (and younger age) of our sample as we showed that knowledge of the distinction is
related to educational level and age. However, we found that only 25% had a deeper understanding and could give an example of
mental handicap.
Our finding that the vast majority of people believe that environmental causes such as 'stress' are important causes of mental
illness is consistent with the findings of other authors. MORI (1990) and Maclean (1969) found that 66% and 83% respectively
saw stress as a major cause.
Previous studies have found that around 50% of people have personal experience of the mentally ill (Maclean (1969) found
that 55% and Richards (1982) found that 42% had experience of the mentally ill); around 30% have relatives with mental illness,
and around 6% admit to having had suffered with mental illness themselves (Maclean, 1969). Our figures are, on the whole a
little higher and may reflect a broader definition of mental illness in our population, a higher pre valence or a higher rate of
reporting.
Our finding that women are more likely to contact a GP than men is consistent with the findings of Brockington et al (1993).
We found that respondents of African and Caribbean origin were more likely to call the police. This may influence pathways into
care in this population.
There was a widespread belief that, the mentally ill were more aggressive than other people (43% believed this). This is in
keeping with previous studies (Belson (1957) Maclean (1969) and Bhugra & Scott (1989) found that 40%, 33% and 17%

respectively perceived the mentally ill as dangerous).


It is interesting that a minority of respondents believed that the mentally ill were more intelligent than other people. They often
described them as more sensitive. This notion may well have its roots in the 18th century Chcynian view of nervous disorders. In
The English Malady, Cheyne (1733) stated:
"The common Division of Mankind, into Quick Thinkers, Slow Thinkers and No Thinkers, is not without Foundation in Nature and true
Philosophy. Persons of slender and weak nerves are generally of the first class".
Reaction to mentally ill people
A minority of respondents (9%) had objections to ex-psychiatric patients living in their neighbourhood. This is similar to the percentage found a
decade previously by Richards (1982). However, a much greater number say that they may treat patients differently, often by being wary of them.
This may well have a bearing on patients' reintegration into the community.
The relationship between knowledge and attitude factors
It was shown in the accompanying paper that there was an association between certain sociodemo-graphic variables and Fear and Exclusion
(having children). Social Control (social class, ethnic origin, age, length of time in the street, having children and

having suffered from mental illness), and Goodwill (educational level, ethnic origin). In this paper, we have shown that Social
Control is the main factor associated with lack of knowledge and that high Social Control groups (except those with children)
have a lack of knowledge about mental illness.
These findings support the hypothesis that one of the underlying determinants of Social Control in these groups is a lack of
knowledge about mental illness. However, these findings do not prove causality and there may well be other confounding factors
which mediate this relationship.
Fear and Exclusion in respondents with children was not related to lack of knowledge of mental illness or the belief that the
mentally ill were actually more dangerous. People with children do not seem to have a different view of the mentally ill but an
accentuated wariness because of their children's vulnrfability.
Conclusion

If there is a causal relationship between lack of knowledge or experience of the mentally ill and negative attitudes, it may well be
that an educational intervention will improve attitudes and this may facilitate patients' rehabilitation. We are testing this
hypothesis by evaluating the effect of an educational campaign on community attitudes and patients' social integration.
Clinical implications
Any interventions aimed at changing attitudes should take into account the negative attitudes of people with children and nonCaucasians.
As negative attitudes are associated with lack of knowledge, education may possibly improve attitudes and help patients'
reintegration into the community.
Socially controlling attitudes and lack of knowledge in people of African and Caribbean origin may have an influence on
pathways into care and have implications for their subsequent clinical management.

Limitations
Our population is not representative of the general population, therefore any inferences drawn about the population as a whole
should be tentative.
The results may be biased by a social desirability response set and people's stated attitudes may not be correlated with actual
behaviour.
The study has not elucidated the main determinants of attitudes as total predictive power was small and associations do not
prove causality.
Appendix 1. Interview questions
(a) Demographic data: age, sex; marital status; composition of household; number of children under 18;
occupation; social class; educational level; length of time in the accommodation; housing tenure; ethnic origin.
(b) Knowledge of mental illness: Do you know the names of any types of mental illness? (What are they?); Do you know what mental handicap
means? (What is it?); Can you give me an example of mental handicap?; Do you think there is a difference between mental illness and mental
handicap? (What is it?); Can you tell that somebody is mentally ill?; How would somebody be able to tell if somebody is mentally ill? (Is it
things they say? Is it things they do? Is it the way they look?); What do you think are the main causes of mental illness?; Do you think that mental
illness can be passed down in families?; If a friend or neighbour of yours was showing signs of mental illness, who would you contact for help?;
What sort of treatment is there for mental illness?; Are mentally ill people more or less likely to be aggressive than other people?; Do you think
mentally ill people more intelligent, less intelligent or the same as other people?; Where did you get most of your information about mental
illness?;
Do you know somebody who has had a mental illness? (Who is it? What is your relationship with them?); Have you, or any member of your
family ever suffered from a mental illness?
(c) Reactions toward the mentally ill: If somebody who had been a former psychiatric patient came to live in the neighbourhood, do you think
people would treat them differently from other people? (In what ways?); Would you treat them differently (In what ways?) Contact with
neighbours and expected contact with neighbours with psychiatric illness. Problems with neighbours and expected problems with neighbours
with psychiatric illness? Would you mind working with somebody who has had a mental illness? What do you think about the idea that people
might have themselves to blame for being mentally ill? Would you/people in the neighbourhood attend a club which ex-psychiatric patients were
also attending? Do you think other people would object to ex-long-stay psychiatric patients living in the neighbourhood? Would you object to exlong-stay psychiatric patients living in the neighbourhood? Would you talk to your friends about a relative who is mentally ill? If you had got
some money to give to charity, which one of these charities would you most likely give to? (Diabetes, mental illness, sick children, cancer.)
(d) Knowledge of psychiatric hospital care: Do you know somebody who is or has been in a psychiatric hospital? Have you visited a psychiatric
hospital?
(e) Attitude to psychiatric hospitals: What is your opinion about psychiatric treatment in hospital? Would you encourage a friend or a relative to
go into a psychiatric hospital if they experienced a mental illness? (0 Knowledge of the shift to care in the community: Do you know of any
alternatives to treatment in psychiatric hospitals? Have you heard about the policy to close psychiatric hospitals and move patients into the
community? If yes, where did you hear about this policy? If yes,
where did you get most of the information about the policy? Is anything like this happening in your area? If yes, where did you hear about this? If
yes, where did you get most of this information about it? Did they know about the hostel? If yes, was it because of our survey? (g) Attitude to
community care policy: What is your opinion of the policy to close psychiatric hospitals? What do you think of the idea of long stay psychiatric

patients being discharged from hospital into small units in the community? What effect do you think this will have on local residents? Overall, do
you think that psychiatric care in the community has a good or a bad effect on local residents?
(h) Opinion about the need for education: Do you think that local residents would offer help for the mental health facilities in their
neighbourhood? What help could local residents give?
Would you offer your help? Do you think it is important for local residents to be given information about new mental health facilities in their
area? What kind of information in your opinion might someone need if patients were going. What do you think is the best method of providing
this information?
Appendix 2. The self-report inventory of fear of and behavioural intentions toward the mentally ill
Respondents were asked to complete a 5 point response scale for each question. Responses were coded on a scale of 1 to 5.
Fear: "I am afraid of people with mental illness" (Responses: strongly agree, agree, neutral, disagree and strongly disagree).
Behavioural intentions: Would you object to having mentally ill people living in your neighbourhood? Would you avoid conversations with
neighbours who had suffered from mental illness? Would you be willing to work with somebody with a mental illness? Would you invite
somebody into your home if you knew they suffered from mental illness? Would you be worried about visiting somebody with a mental illness?
If somebody had been a former psychiatric patient, would you have them as a friend? If somebody who had been a former psychiatric patient
came to live next door to you, would you greet
them occasionally? Would you have casual conversations with neighbours who had suffered from mental illness? If somebody who had been a
former psychiatric patient came to live next door to you, would you visit them? (Responses: very likely, likely, uncertain, unlikely, very
unlikely.)