DSQ > Winter 2008, Volume 28, No.1
Abstract

In the last two decades, we have witnessed a significant change in the quality of life and social participation of people with psychiatric disabilities. This article examines staff's and consumers' attitudes toward inclusion of persons with psychiatric disabilities, to understand whether the two groups see eye to eye regarding this important goal. The sample included 88 persons with psychiatric disabilities living in six community settings in the north of Israel, and their 54 direct and supervising staff. The findings showed that the two groups had similar favorable attitudes toward inclusion, except in the empowerment factor, where consumers' attitudes were more favorable. In addition, professional staff showed more positive attitudes toward inclusion than non-professional direct staff.

Background

Since the 1960s, the recognition that exclusion and segregation of people with disabilities is not a logical outcome of their impairment, but results from political choices based on false assumptions about disability, has grown. In recent years, disability has ceased to be viewed as an individual problem (as projected by the medical model). The focus has now shifted to how the environment and society as a whole fail to consider human differences (Johnstone, 2001). This paradigm shift from the medical model of disability to a social and political model has lead to its reclassification as a human rights issue under international law (Bickenbach, 2001).

The Americans with Disabilities Act (ADA) that was passed in the United States in 1990 was a watershed event for disability rights on the international stage (Bickenbach, 2001). The ADA recognized that the main problem confronting people with disabilities did not lie in their individual impairments, but in discrimination against them through purposeful unequal treatment and historical patterns of segregation and isolation. The ADA bars discrimination against people with disabilities in employment, public services, public accommodations and telecommunications

Since its enactment in the United States, many countries have passed similar disability laws, shifting the focus from a social welfare approach to a human rights approach. In 1998, the Israeli Knesset passed the first three sections of the new Equal Rights for Persons with Disabilities Law (Rimmerman & Araten, 2005).

However, a significant discrepancy still exists between the law and its implementation, as apparent in the lack of accessibility and inclusion of people with disabilities in Israeli society (Rimmerman & Katz, 2004). Rehabilitation specialists have departed from the medical model to adopt the social model in an effort to break down societal barriers against people with disabilities. This is not so simple, as most of their clinical knowledge and practice is based on the medical model.

The Medical Rehabilitation Model

This is the oldest model, and has been used primarily within medical institutional care. This body-centered model views rehabilitation through the negative impact that certain impairments may have on the individual's level of functioning.

Based on this conceptualization, the rehabilitation specialists' role was to assess impairments, functioning and interventions with the aim of reducing the occurrence of potential handicap situations and of achieving maximum independence (Pedretti & Zoltan, 1990). The model emphasized professional expertise and elitism in all processes of remediation of damage caused by illness, and the development of deficit-specific treatment methods. Hence, rehabilitation experts and services were provided according to impairment and specialization in certain disability categories.

The model contributed significantly to assessment and development of a knowledge-base regarding interventions with special types of disabilities. However, it was criticized for focusing too much on the impact of impairment on functioning and less on the role of social ecology, particularly the importance of community services for the individual's participation and well-being (Bickenbach, 2001; Johnstone, 2001).

Professionals who based their main practice on the medical model became gradually aware of its negative effects on their clients. These included low self-image, loneliness, dependency and anxiety, as well as loss of employment, which lead to economic distress, and divorce (Kendall, 2003; Martz, 2003). In addition, rehabilitation counselors and psychologists recognized the importance of studying coping strategies as related to specific disabilities (Antonak & Livneh, 1988; Maes, Leventhal, & Ridder, 1996).

The New Socio-Model

The World Health Organization's (WHO) definition of rehabilitation also reflects these changes. It published the ICF-International Classification of Disability, Function and Health (WHO, 2001), which states that the goal of rehabilitation staff is to promote the individual's health, welfare and participation in social roles.

The ICF document raises the importance of environmental adaptations, by differentiating between involvement within a therapeutic protective frame (capacity) and actual participation within the community (performance). It relates to various areas of participation: Mobility, self-care and house maintenance, work/studies and social activities within the community. It is society's responsibility to initiate and intervene in removing obstacles within the environment (Barnwell, & Kavanagh, 1997; Mizra, et al., 2006). Professional and public attitudes to inclusion are among the major barriers.

The recent change in rehabilitation is the adoption of the social model. This model constitutes a conceptual framework for understanding disability as a social outcome and a form of social repression (disablism), with emphasis on analysis of factors that exacerbate the difficulties and affect the capabilities of persons with a disability to perform various social roles (Barnes, 1996; Barnes, Mercer, & Shakespeare, 1999; Denney, 1998; Oliver, 1989, 1990, 1996; Thomas, 1999). Theories concerning the social and cultural processes that generate negative attitudes to disabilities and impairments, and affect the sense of self and self-esteem of persons with a disability were also developed (Crow, 1996, Morris, 1996; Shakespeare, 1994; Thomas, 1999). Morris (1996) argued that portrayals of the disability experience should depict the persons with disabilities' difficulties, the discrimination and prejudice against them, and their struggle against social oppression to attain self-esteem and self-determination. Crow (1996) claims that persons with disabilities are concerned that the discussion on disability may be exploited and used against their struggle for social change, and may silence the disability experience. However, their willingness to share their experiences could reinforce the collective challenge to social oppression and efforts to uproot society's conventional interpretation of disability.

Several forces have lead to this change. The first is probably due to policy shift from institutional toward community care and the role played by socio-political human rights movements. They awaken awareness among people with disabilities, seek ways to be involved and gain control over resources, and influence given services (Berkowitz, 1992).

On the other hand, the change is seen as a development of the relationship between the state and its citizens with disabilities. The state begins to view disability as a social rather than personal problem. Consequently, it is society's responsibility to allow all its members, including those with special needs, to participate by right and not as a matter of benevolence (Fougeyrollas & Beauregard, 2001). These movements have advanced legislation in many countries, landmarked by the ADA in 1990 ( ADA, 1990; Hudgins, 2005). Since then, the approach which viewed people with disabilities as an equal-rights minority has become more humanistic, and has related to the diversity that exists among all citizens, who should define their special needs themselves These citizens were no longer defined as patients, but as clients, with the ability to choose the best service provider. In the adopted client-centered approach, the client with special needs is the real subjective case manager. The services also had to adapt themselves to the client-centered approach in all aspects: Evaluation, goal determination, ways of intervention and treatment quality monitoring. The other side of the coin is that clients are required to be involved They need to take responsibility for promoting and preserving their good health through preventive behaviors, as well as participate in occupations within their community (Falardbeau, & Durand, 2002).

In the last two decades, Israeli government policy has been to release persons with psychiatric disabilities from psychiatric hospitals into the community. This trend has developed as a continuation to the de-institutionalization movement and the community psychiatric rehabilitation approach, which triggered a shift from the medical model and institutional framework to a social model (Geller, Fisher, Wirth-Cauchon & Simon, 1990). The goal of such an approach is to enable individuals with psychiatric disabilities to maintain as normal a life as possible (Antony et al., 2001; Corrigan, Calabrese, Diwan & Kegh, 2002; Carrie & Krupa, 2002). This trend was translated into a new policy and legislation, resulting in the passage of the rehabilitation law — the Ministry of Health's or "Rehabilitation Basket" in 2000 — which defined the different aspects of rehabilitation services for persons with psychiatric disabilities in the community (Rimmerman & Araten, 2005)

New emphasis has been placed on patient autonomy as a central value in health promotion. It recognizes the individuals' right not only to participate in the decision-making process about their own treatment plan, but also to mold the course of care in light of their values and goals (Henderickson-Cracie, Staley, & Neufeld-Morton, 1996). In principle, autonomy refers to the individual's basic right to self-determination. This basic right includes freedom of choice in selecting a life plan as well as in the steps involved to carry it out. In rehabilitation terms, it includes freedom of choice among the range of residential, vocational, educational and social opportunities in the community. However, in spite of all the positive change that has accrued, it is still commonly acknowledged that actual presence in the community does not ensure full integration in society, unless a real change in attitudes has occurred (Carrier & Krupa, 2002; Geller, Fisher, With-Cauchon & Simon, 1990).

Attitudes

Many studies have focused on attitudes toward persons with disabilities. The literature presents different theoretical approaches to defining attitudes. It describes the manner in which the attitudes are formed and the variables that influence them Variables found to be influential include gender, age and education (Ajzen, 2001; Albarrancin, Johnson, & Zannal, 2005; Yuker, 1986). Their common basis is that the attitudes reflect personal and environmental interaction Reviews of early studies pointed to stereotypic attitudes held by various population groups (Antonak & Livne, 1988). In contrast to extensive research focusing on the existence of negative attitudes, relatively few studies have focused on attitude modification (Stiller, 1984). Seven components of human attitudes toward persons with disabilities have been identified: Discomfort in their presence; misunderstanding their behavior; antagonism; general negative attitude; the need to treat them differently; fear of being hurt; disbelief in one's abilities (Stiller, 1984).

In addition, new definitions of disability and functioning have been formed, as well as new theoretical models that explain the issue of coping with disability. Alongside the theoretical changes, the system has had to face the reality of economic policy, so the services are required to prove their efficiency and outcome measures. All this has been part of the shift to the social rehabilitation model.

Staff Attitudes

Staff attitudes affect the extent to which the inclusion philosophy becomes reality (Henry Duvdevany, Keys, Balcazar & Jopp, 2004). Early in their employment, staff attitudes may resemble those of the general public, but they are gradually shaped by numerous official and unofficial influences. These include training, co-workers' attitudes, overt agency values, covert organizational norms and values and personal experiences with this population. Staff attitudes affect their work motivation and the quality of service that persons with mental illness receive (Balcazar et al., 1998; Henry et al., 2003; Rivlin, 2002)

A highly paternalistic manner of practice has traditionally existed in the mental health field. This is partly the result of the difficulty in balancing individuals' rights and freedom with the strong sense of protecting their best interests. Many studies claim that the professional community has generally defined its therapeutic goals according to its values and beliefs and not in accordance with consumer needs. Exposure to a more humanistic approach helps to encourage more positive attitudes (Holmes, Corrigan, Williams, Canar & Kubiak, 1999).

Workers in supervising positions, who believe in autonomy and self-determination for persons with disability, tend to involve their consumers in the decision-making process and try to help them achieve goals that suit the consumers' needs and wishes (Nelson, Hall, Walsh-Bowers, 1999). In general it has been found that all supervising staff working in the community settings, irrespective of their specific professions, tend to favor integration of persons with mental disabilities into the community and have a more positive attitude than the supervising staff in hospitals. (Rivlin, 2002).

Persons with disabilities report that they are hardly ever asked what they really want to change or what kind of help they prefer (Antony, Macdonald-Wilson, Nemes & Cohen, 2001; Webb, Clifford, & Graham, 1999). Review of the literature regarding the consumers' views and attitudes reveals a discrepancy between the perceptions and attitudes of psychiatric staff and consumers. The failure of formal support services to fulfill their social and health needs is one of the major factors in the development of self-help and self-advocacy organizations that serve as mutual aids and advocacy forces against the discriminatory and unjust policy of the establishment (Lachman, 1998). Many professionals believe in making consumers' voices heard and in giving more attention to their demands and goals during treatment (Deegan, 2003; Furbestein & Hidsh, 1997). A number of evaluation and treatment programs have been developed recently, based on the consumers' reports of their goals and needs (Frager, Coyne, Lyle,Cooutler, Graham, Sargent & Allen,1999).

The purpose of this study was to explore the barriers preventing full inclusion and participation of persons with psychiatric disabilities in the community, by examining the differences between staff members' and consumers' attitudes to this population's inclusion.

Method

Sample

The participants of this study were recruited through the Ministry of Health Department for the Treatment of Persons with Psychiatric Disabilities. With their permission, we sent invitations to participate in the study to all the community settings in the North. Eighty-eight persons with psychiatric disabilities in six community living settings, and 54 staff members who treat them agreed to take part in the study. All six settings are in the Haifa and Hadera area — two major cities in the north of Israel. These settings are part of a national community living arrangement. They house between eight and 10 persons, and employ between six and 15 treatment and supervision staff. These include directors, social workers, students, direct staff, house parents and volunteers.

All consumers and staff were asked to participate in the study, and most of them (above 80%) agreed. Table 1 presents a comparison of the participants' characteristics.

Table 1. Demographic characteristics of persons with mental illness and their staff members
Variable Patients with mental illness Staff members Difference
N % N % Z
Gender
Male 62 70 11 20 Z=5.78***
Female 26 30 43 80
Age
21-25 7 8 25 46
26-34 14 16 12 22
35-44 31 5 5 31 Z=4.59***
45-54 30 34 8 15
55-64 6 7 4 8
Family status
Single 70 80 26 48
Married -- -- 20 37 Z=3.87***
Divorced 14 16 7 13
Separated 3 3 1 2
Widower 1 1 -- --
Education
Elementary school 25 28 1 2
Partial high school 36 41 3 5 Z=8.06***
High school 22 25 14 26
Academic 5 6 36 67
Role
Consumers 88 100
Manager 4 7
Social worker 9 17
Student 9 17
Guide 18 33
Housekeeper 11 20
Volunteer 3 6

Notes:

1. * p<.05, ** p<.01, *** p<.001.

2. Family status: The difference is between "single" and all the rest.

Table 1 shows that approximately 70 per cent of consumers were men and 80 per cent of staff members were women. The staff members were significantly younger than the consumers. Seventy per cent are under 35 years old, while the same percentage of consumers were between 35 and 55 years old. Seventy per cent of consumers had only elementary or partial high school education and only 25 per cent had full high school education, while 70 per cent of the staff had higher academic education, and 25 per cent had high school education. The staff comprised 41 per cent professionals and 59 per cent paraprofessionals.

Measurements

1. Demographic questionnaire that included variables such as age, gender, education, family status and information about the professional roles and background of staff members.

2. CLAS-MR — The Community Living Attitudes Scale, developed by Henry et. al., (Henry, Keys, Jopp, & Balcazar, 1996), based on the input of self-advocates. It focused on contemporary community-living philosophies. The original scale was developed for persons with psychiatric disabilities and dual diagnosis The Hebrew version was prepared by the author and was back-translated to English by an external examiner. A comparison of the two versions was then carried out. The Hebrew version included all 40 items.

The scale was a 40-item measure consisting of four subscale measures: (a) Attitudes toward empowerment and self-advocacy (13 items); (b) The respondent's desire to exclude persons with mental retardation from community life (seven items); (c) The extent to which the respondent believes that persons with mental retardation need to be sheltered or protected (seven items); (d) The perceived similarity of persons with mental retardation to oneself (12 items). These subscales demonstrated acceptable internal consistency (.75-.86), and retest reliability (.70-.75) in one month. Evidence for construct validity was found to be in correlation with other attitude scales. Correlation with a measure of social desirability showed that the subscales were relatively free of social desirability bias (Henry et al., 1996).

In this study, the internal consistency for the four factors were: (A) Empowerment — a.=76; (b) Exclusion — a=.72; (c) Sheltering — a=.68; Similarity — a=.76. Higher scores reflected a positive attitude in empowerment, a negative attitude in exclusion, a negative attitude in sheltering and a positive attitude in similarity. The Pearson's correlation between the four subscales is presented in Table 2. The correlations of the Hebrew version were similar to the American version CLAS-MR — The Community Living Scale (Henry et al., (1996).

Two closed questions were used to examine the involvement of consumers with psychiatric disabilities in the decision-making process:

  1. Should the consumer be consulted about his/her preferences? (yes/no).
  2. Who should be involved in the planning of the consumer's personal treatment plan?

The answers were arranged in a hierarchical empowerment order — staff alone; staff and consumer; staff, consumer and consumer's family; consumer alone.

Procedure

After receiving written permission from the directors of the community-living settings, interviewers were sent to each agency with questionnaires. The respondents were asked to indicate the extent to which they agreed or disagreed with the statements above on a six-point scale, ranging from 1=strongly disagree to 6= strongly agree. The interviewers then collected all questionnaires for data analysis.

Hypotheses

  1. Staff attitudes toward the inclusion of persons with psychiatric disabilities will be more positive than the consumers' attitudes.
  2. Workers in high positions with more years of seniority will have more positive attitudes than direct staff workers with fewer years of seniority.
  3. Workers who have been through higher education will express more positive attitudes toward the inclusion of persons with psychiatric disabilities than workers who have not received higher education.
  4. Staff workers in professional positions will have a stronger belief in the need to include consumers in the decision-making process about their future than the paraprofessional workers.
  5. Female workers will express more positive attitudes toward the inclusion of persons with psychiatric disabilities than male workers in both groups.

Findings

Attitudes toward community inclusion in both groups

To examine the attitude toward the inclusion factor in both groups, multivariant analysis of covariance (MANCOVA) was used. Significant differences were found between consumers and staff in the empowerment factor: [F (4,135)=7.06 (p<.001)]. Persons with psychiatric disabilities expressed much stronger support for the empowerment of this population in the community than the staff. In the other attitudes scale factors, no differences were found Therefore, the hypotheses were not fully confirmed.

Table 2. Multiple Variance Analysis of attitudes of staff and consumers toward inclusion in the community
Attitudes staff consumers F(1,138)
M SD M SD
empowerment 3.92 .54 4.16 .82 10.49**
isolation 2.18 .70 2.44 .81 .04
sheltering 4.14 .70 2.25 .84 .39
similarity 4.95 .59 4.46 .66 2.24

Notes:

1. *p<.05, **p<.01, ***p<.001

Attitudes toward involving consumers in the decision-making process

The belief concerning the need to involve consumers in the decision-making process was examined by two questions that were added to the questionnaires. The results revealed that both groups supported the idea that consumers should be involved in decisions about their future (Z=.32).

Table 3. Attitudes of persons with psychiatric disabilities and their staff members toward the need to be involved in the decision-making process
Should we ask the persons with mental illness about their preferences?
Persons with psychiatric disabilities Staff members Difference
N % N %
Yes 88 100 54 100
No -- -- -- -- --
Who should be involved in the decision-making regarding personal programs for persons with mental illness?'
Persons with psychiatric disabilities Staff members Difference
N % N %
Staff member 6 7 6 11
Staff member and the consumers 62 71 32 59 Z=.32
Staff member, consumers and their families 10 11 9 17
Persons with psychiatric disabilities 10 11 7 13

Correlations between inclusion and involvement in decision-making

Spearman correlations between the attitudes toward consumers' inclusion in the community and their involvement in decision-making for their future showed a correspondence between the two. Persons with psychiatric disabilities, who supported integration in the community, also supported the need to be involved in decisions for their future. Staff members who recognized similarity and did not support sheltering, also believed in the importance of consumers' involvement in the decision-making process. Therefore, we can assume that there is correspondence between the two.

Attitudes toward inclusion according to the role and position of the staff

MANCOVA analysis of attitudes toward inclusion in the community according to professional role revealed significant differences between professional staff members and paraprofessional workers: F(4,47)=2.89 (p<.05).

Table 4. Multi Variance Analysis (MANOVA) of the attitudes toward the integration of persons with psychiatric disabilities in the community divided by staff members' role
Attitude Professional Paraprofessional F (1,51)
M SD M SD
Empowerment 4.13 .50 3.77 52 5.14*
Exclusion 1.89 .57 2.38 73 5.34*
Sheltering 3.87 .63 4.33 69 3.71
Similarity 5.26 .41 4.74 61 8.02**

Notes:

*p<.05, **p<.01, ***p<.001

Attitudes according to education

Those who had received higher education revealed more positive attitudes toward integration than those who had received only high school education Significant differences were found between the two groups in the empowerment, similarity and isolation factors. Education level revealed a significant difference between those with academic education and those with high school education: F(4,47)=2.89, (p<.05) In all four factors of the attitudes scale, those with academic education had much more positive attitudes toward the integration of persons with psychiatric disabilities in the community.

The fact that 91 per cent of the professional workers had academic degrees and 89 per cent of the paraprofessional had only high-school certification aroused the need to examine which of the two factors have more impact on the differences in attitude. Two multiple analyses were performed with control on age and education. One was on attitudes according to the role with control on age and education, and the other on education with control on age and role. Neither were significant: f(4,47)=1.48 for role and f(4,46)=1.43. (n.s.) We can assume that role and education have similar influence on the attitudes.

Attitudes according to gender

Multivariant analysis of variance (MANOVA) was used to analyze differences according to gender, in the staff and consumer groups' attitudes toward inclusion of persons with psychiatric disabilities. The results were not significant. F(4,83)=2.05, for the consumers and F(4,49)=.26 for the staff. In general, no significant differences were found between the two groups. The only significant difference was found in the similarity factor, where women consumers scored higher than the staff, with 7.49 (p<.01) in the similarity factor, but there were no differences in the other factors. The same result was found in the staff group.

Table 4. Multi Variance Analysis (MANOVA) of the attitudes toward the integration of persons with psychiatric disabilities in the community divided by staff members' role
Attitude Male Female F
M SD M SD
Persons with psychiatric disabilities
Empowerment 4.11 85 4.30 75 1.05
Exclusion 2.52 .86 2.26 63 1.89
Sheltering 4.29 86 4.15 80 52
Similarity 4.34 .69 4.75 49 7.49**
Staff members
Empowerment 3.82 68 3.94 51 40
Exclusion 2.28 .90 2.15 66 29
Sheltering 4.14 84 4.14 67 00
Similarity 4.99 .68 4.94 58 04

Notes:

1. *p<.05, **p<.01

2. For persons with psychiatric disabilities F(1,86), and for staff members (1,52)

Attitudes according to age

The relationship between age and attitude was examined by Spearman correlation in the two groups. In both groups, significant differences were found in age. In the consumer group, younger persons had more positive attitudes in the empowerment and similarity factors. A greater number of older consumers supported exclusion of persons with psychiatric disabilities. In the staff group, the younger the workers were, the more positive their attitudes in the similarity factor. In the sheltering factor, a larger number of older workers than younger workers supported sheltering. Young persons with psychiatric disabilities give greater support to empowerment, sheltering and similarity factors than young workers, who give greater support to the sheltering and similarity factors Therefore, the hypotheses of the study were examined in control of age and gender in both groups, and of gender in the consumer group.

Table 6. Correlations between participants' age and attitudes toward the inclusion of persons with psychiatric disabilities in the community, divided by consumers and staff members
Attitude Consumers Staff members
Empowerment -.26* -.19
Isolation 20 .30**
Sheltering 14 .35**
Similarity -.23* -.37**

Note:

*p<.05, **p<.01

Family status was not found to be significant in the differences between the attitudes: F(4,40)=.13 (N.S.).

Discussion

In this study, we examined the attitudes of consumers and staff members concerning the integration of persons with psychiatric disability who live in the community. The release of such persons from institutions means not only limiting the number of patients in institutions, but also dealing with the negative aspects of institutionalization (Rivlin, 2002). The examination was conducted according to age, gender, level of education and role status. The attitudes were measured according to four factors: Empowerment, sheltering (the need for sheltered settings), exclusion (the need to segregate them from the regular population) and similarity (to what extent they are different or similar to the non-disabled population).

High scores on empowerment and similarity and low scores on sheltering and exclusion, point to strong support of the integration ideology and to the positive change in attitudes toward persons with psychiatric disability who live in the community. In addition, the participants were asked if there is a need to involve the persons with psychiatric disability in the planning of their personal and therapeutic programs.

The professional therapeutic model had changed in that it now supported the re-entry of persons with psychiatric disabilities into the community and had developed a therapeutic intervention plan to promote social skills for community living (Bickenbach, 2001; Zaura, Hamilton, & Yocum, 2000). This convinced us that the staff's attitudes toward integration into the community of persons with psychiatric disabilities will be more positive than those of the consumers themselves. Surprisingly, we found that the consumers' attitudes were more positive in relation to empowerment than those of their staff. But in the exclusion, similarity and sheltering factors, no differences were found between staff and consumers. It seems that in spite of the negative experience of persons with psychiatric disability, the transition into community-living arrangements increased their positive beliefs in their ability to integrate in the community and they became more optimistic for successful rehabilitation. In the early stage of the rehabilitation process, when the persons with psychiatric disability have low expectations of their capabilities, it is the staff's duty to give them hope and belief in their ability to re-enter the community. In the run up to discharge from the hospital, the staff has an important role in reassuring and reducing stress to prevent regression (Bellus, Kost, & Vergo, 2002). In many cases, the staff's intervention has damaged their consumers' quality of life, by misinterpreting their behavior. The rehabilitation process should include support and dependency so that the consumers will not feel abandoned (Lahman, 1998). An Israeli hospital has opened a special unit, developed as a rehabilitative setting for persons who have been discharged from the hospital and who are making their first steps in the community. In this setting, consumers receive training in different aspects of independent living and become partners in their own therapeutic plan Three major areas were found to be essential: ADL-living skills, social skills and vocational skills. The development of many new projects by the consumers and self-advocates were also a major factor in supporting and encouraging professional and family members to promote the inclusion of persons with psychiatric disabilities in the community. Since 1997, there has been an increase in the work of self-help organizations, such as "BENAFSHENU" that was jointly initiated by consumers and service workers. This is a unique service, as the BENAFSHENU staff are people coping with mental illness. Their personal experience instills trust and mutual understanding, enabling them to act as mediators between the consumers and the establishment, to promote the consumer population's quality of life (http://www.benafshenu.jerusalem.muni.il) Another project is "LAHAK," which promotes leadership development among the population with psychiatric disabilities, who then serve as role models for their members. Participation in this kind of project opens up opportunities to take part in many developing projects, such as "Voices" (http://www.voices.co.il), a website established in 1997, where consumers can write information, translate professional articles, and upload personal stories and their own works of art. The Internet has become a powerful vehicle for empowerment and accessibility to the media, enabling interaction between people, especially for those who have difficulty leaving the house It provides them with a platform where they can express themselves through art, poetry, literature and academic writing and can also receive counseling and practical information via the website The impact of self-help organizations has increased hopes and beliefs, and professionals and consumers are now running various types of joint training programs, with mutual recognition of the special impact of each group (Lachman, 1998; Rivlin, 2002).

Both groups responded positively to the need to involve consumers in planning their own future. A correlation was found between the positive attitudes toward involving consumers in their future plans and positive attitudes toward integration in the community, in both groups. Those who believed in integration also believed in involving consumers in decisions about their future plans. These findings confirmed results of other research into the importance of consumers' involvement in therapeutic planning and decision-making.

The hypothesis that staff with a professional role in rehabilitation will have more positive attitudes toward the integration of their consumers was confirmed. Social workers, directors and other rehabilitation workers expressed more positive attitudes in three factors: Empowerment, similarity and inclusion. The direct staff, for example, the manager, instructors etc., had less positive attitudes. These results confirmed previous studies, such as Duvdevany, 2000; Henry, Keyss, Balacazar, & Jopp, 1996. In these studies, the higher the staff members' position, the more liberal and humanistic are their attitudes. They tend to be less authoritative, restrictive and less stigmatic toward these persons than the non-professional workers. The fact that most professional workers (91%) had received an academic education, and the paraprofessionals (89%) had received only high school education, emphasizes the importance of knowledge as a means to changing attitudes. Many studies on knowledge and attitudes indicate the role of knowledge in changing attitudes toward persons with disabilities (Ajzen, 2001; Duvdevany, 2000; Henry et al, 1996b). It seems that education and a professional role have the same impact on changing attitudes, and are the major factors in attitude development.

The age factor was found to be significant in attitude development. In general, young persons have more positive attitudes than older people. They are more tolerant and liberal than older members of staff. As they acquire greater seniority in the field, they tend to keep more of a distance and view psychiatric disabilities more scientifically than humanistic ally (Duvdevany, 2000; Henry et al., 1996b; McReynold, Ward, & Singer, 2002).

In sum, in this study, we attempted to examine the differences in attitude between staff and consumers. The results show limited differences between the two groups. Most of the participating population seemed to believe in the right of persons with psychiatric disability to be involved in the decision-making process regarding their future, and in the need for integration in the community as a major goal in their rehabilitation. The differences in attitudes among the staff were mainly a result of their education and professional role. Most of the staff had been educated on the medical model, and their beliefs still retained some of the barriers. It is therefore very important to learn how the past has an impact on the new era.

The literature review and follow-up research both demonstrate the current transition status between the medical and social models. They also reflect the gap between the potential for enhancing people with disabilities' functioning and participation, and actual implementation. This may have consequences for rehabilitation practice, policies, service delivery provision, as well as for professional education and academic work.

Today, our outcome measure is not only the clients' functioning, but also their ability to fill demanding roles in society. Considering the demanding pace of modern society, it is imperative to act and modify within the consumers' work environment, to enable them to participate and fulfill their roles. While environmental and technological adaptation opens up new opportunities for clients, it does not always ensure maximum participation.

Based on our study, we became aware that bridging between persons with disabilities and their environments is insufficient. It is also important to change the attitudes of professionals and policymakers toward their consumers.

The main progress in rehabilitation up until now has been legislation. The challenge lies in mobilizing resources, creating evaluation instruments to assess adaptations, providing advocacy to underprivileged groups and creating new intervention modes with the assistance of other social and health experts.

Our research calls for the use of comprehensive and multi-faceted measures, such as subjective appraisal (e.g., disability perception and self-image questionnaires), alongside expert observation. By the same token, there is a demonstrated need to cooperate with professional experts from other fields regarding our clients, to design various measures for human and physical environmental change.

These future challenges must not overpass changes in professionals' education such as the inclusion of social and cultural contexts in the rehabilitation curriculum.

However, it is impossible to move forward without the critical input of the people with disabilities themselves. It is therefore imperative that they take part in the political process and engage in a dialogue with society's non-disabled sector. In addition, there is a need for open dialogue between people with disabilities, legislators and the public at large. This is a golden opportunity for the Equal Rights Commissioner for People with Disabilities to play a crucial role in initiating and promoting the debate about the priorities and goals of change. Finally, social scientists have to study inequalities between people with and without disabilities longitudinally and to shed light on the areas in need of greater civil and social participation.

Limitations of the study

The results of this study are limited to six different agencies in the north of Israel, and they are not applicable to the entire Israeli population with psychiatric disabilities. Future research should focus on other variables that may have impact on staff attitudes, and on methods of increasing the commitment of all staff members to empower community living for persons with psychiatric disabilities. Consumers should be more involved in the decision-making process and new methods for increasing their social and personal skills need to be developed. Changing attitudes is one step in developing an organizational culture that sustains and rewards action toward implementing an empowering, inclusive philosophy. Considerable effort and expense may be necessary to institutionalize the positive socialization of present and potential staff members and consumers.

References

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