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Sociocultural and Socio-Psychological Factors Affecting Personal Responses to Psychological
Disorder
Author(s): David Mechanic
Source: Journal of Health and Social Behavior, Vol. 16, No. 4, Special Issue on "Recent
Developments in the `Sociology of Mental Illness'" (Dec., 1975), pp. 393-404
Published by: American Sociological Association
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Sociocultural and Social-Psychological Factors
AffectingPersonal Responses to
Psychological Disorder*
DAVID
MECHANIC
University
of Wisconsin-Madison
SOCIOLOGISTS
and social psychologiststificationand care, and that insightsre-
have given considerable attentionin
recentdecades to the processes leading to
the identificationof mental disorders in
the communityand to factors affecting
help-seeking. Such work was given impetus almost twentyyears ago with the
publicationofSocialClassandMentalIllness
(Hollingshead and Redlich, 1958) and its
analysis of social class differences in
thresholds for identifyingmental disorder and pathways into care. At approximatelythe same time Clausen and
Yarrow (1955), then at the National Instituteof Mental Health, in a studyof the
families of schizophrenic patients, detailed the processesof denial and normalization that resulted in delays in seeking
care untilthe patient'sbehaviorbecame so
bizarre and difficultto cope with that
treatmentwas initiated.A varietyof other
studies examined the instrumentalfunctioning of mental patients in the communityand factorsrelated to rehospitalization (Freeman and Simmons, 1963; Dinitzet al., 1962; Brownet al., 1966). These
studies were consistentin findingthatrehospitalization was related less to instrumentalfunctioningthan to the manifestationof bizarreand difficultbehavior
thatsignificantothersfound hard to manage.
Medical sociologywas then at an infant
stage, and these early studies stimulated
enthusiasmand interest.They illustrated
thatsociologicalmethodscould be applied
to problems of mental illness, its iden-
in part by Public Health Service
*Supported
GrantMH 20708, and a grantfromthe RobertWood
Johnson Foundation.
sulted through such investigation that
were not apparent fromclinicalresearch.
It is difficultto believe, but nevertheless
true, that until the publication of Hollingshead and Redlich, psychiatristsand
other mental health personnel largelyignored social class and the subcultural
stylesitembodies as importantvariablesin
understanding and dealing with mental
illness. Although trite today, the demonstrationtwentyyears ago that recognitionof symptoms,pathwaysintocare, and
response to treatmentwere related to social class and subculturalpatternswas of
verygreat interest.
I have begun this article with a brief
historical overview because it illustrates
inherentin undersome of the difficulties
standing the processes of personal
response today. While in the 1950's and
1960's it was useful to demonstrate the
importanceof social variables in explaining various processes related to mentalillness and its treatment,the task is much
more demanding today. It is no longer a
revelation that social class, ethnicity,or
household structureare correlated with
dependent variablesof interest.The field
is presently grasping for a theoretical
framework that ties together disparate
studiesintoa more coherentwhole. While
the literature abounds in reports of
studiesillustratingthatone or anothersocial variable is associated withrecognition
of having a problem, with help-seeking,
withretentionin treatment,or whatever,
thesereportshave a tedioussimilarity,
giving the impression that although the effortis considerable the yield is relatively
small. What clearlyseems necessaryis not
393
394
JOURNAL OF HEALTH
AND SOCIAL BEHAVIOR
more studies in the same vein, but clarificationof the theoreticalproblems,formulation of the issues that remain problematic,and reviewof the most adequate
methodologies that facilitatetheir clarification.This review,thus,is not a summary of the many studies done but, in
contrast,an attemptto specifywhere we
are and where we must go if'we are to
advance studyof personal responses and
help-seeking.
SomeTheoretical
Issues
The areas of concern here fall most
properly into an aspect of sociological
theory that might be referred to as the
studyof social selection.Social selectionis
one of the most pervasive processes
characteristicof human communities,and
itsstudyconcernsthe identification
of underlyingprinciplesof sortingand resorting thatcontinuouslygo on among social
groups. Subareas of the study of social
selectioninclude assortativemating,geographic migration, selection related to
education, life careers and achievement,
and numerous other topics. Social selection ideas have become increasinglyimportant in theoreticalconceptions of deviance where attentionis directed to the
social processes throughwhichparticular
persons are identified, processed, isolated, and are confrontedwithrestricted
opportunity structures (Lemert, 1951;
Scheff,1966b; Matza, 1969).
In making sense of processes of social
selection, whatever the subarea of concern, attentionis given to the particular
characteristics of the individuals and
groups involvedthatmake themdifferent
in one way Or another fromothers in the
community.Attentionis also given to the
processes by which they interact with
oth-ers exchanging information about
their social characteristics,skillsand disabilities,and personal inclinations.Efforts
must also be made to understandthe underlyingopportunitystructiiyethatmakes
choice possibleand thateither
dif'ferential
facilitatesor letards certain possibilities.
In short,selectionproblemshave personal, interactional,and structuraldimensions.
Although social selection is one of the
most central processes of' social activity,
much of sociologicalinvestigationviewsit
more as an irritationthan as an object of'
inquiry.Because social selection is such a
powerful process, sociologistscannot ignore it,but in order to maintaincredibility
they must successfullydiscount it. Thus,
students of complex organization, comparingvaryingtypesof social structuresor
managementstyles,mustmake a credible
case thatit is the structuralarrangements
thatare reallyimportantin contrastto the
types of persons drawn to varyingorganizations.Investigatorsof'education or
othersocial programsmust,in order to be
taken seriously,convince uS that the eff'ectstheyobserve are related to a specific
interventionin contrast to the types of'
clients drawn to varying kinds of programs. Indeed, some social scientists,recognizing the power of'selection,take the
position that serious study without the
randomizationof'selectioneffectsis futile.
Most curious about all of'this is that,despite such widespread recognitionof' social selectionas a powerfuland pervasive
social process, so few sociologiststake selection itself'as the object of'theirtheory
and inquiry.
varying
It is quite possibleto f'or-mulate
hypothesesabout selection that have importantimplicationsfor how we constlrue
social processes more generallyand what
policy implicationswe derive from such
understanding. Take, f'orexample, the
simple instance of' a patient seeking the
assistanceof'a physician.One hypothesis
about selection is that it basicallyreflects
the magnitude,quality,and seriousnessof'
symptoms. This "rational" concept of'
medical utilization would lead one to
of'illnessare
anticipatethatcharacteristics
the main determinantofIuse of'physician
services, and that exceptions flow from
ignorance, misperception,or pool communication;and, of'course, thisis the way
many physiciansxiew the utilizationprocess. A contrasting hypothesis would
maintaini that many of' the problems
brought to a physician resemble similair
problemsof'con-siderableprevalence that
only occasionally lead to care; thus,
knowledge of symptomsis not sufficient
to make sense of' the use of' physicians.
PERSONAL RESPONSES
TO P'SYCHOLOGICAL
DISORDER
395
What may differentiatethose who seek though there are extensive reports and
care fromthose who do not is a desire for discussions on the "hidden agenda" in
social support,secondarygain as reflected medical consultationsand numerous atin release from work or from other ob- temptsto analyze people's deeper motivaligations, or some other social process tionsforseekingcare when theydo so for
quite unrelatedto theillnessor symptoms. psychologicalproblems(see Balint, 1957),
The perspectivetaken on a problem as it is difficultto investigatethese issues in a
seemingly simple as medical utilization rigorous and replicable manner. Genmay have importantimplicationsfor the erally speaking, there are four methodtypesof questions asked, as well as a vari- ological approaches to understandety of' practical concerns. To the extent ing how people respond to symptoms
thatthe discrepancybetweenthe character and choose pathwaysfor care.
and magnitudeof'illnessand utilizationis
1. StudyofCare-Seeking
as a Dispositional
seen as littlemore than the resultof'dis- Varilblet:
One wayof attemptingto undertortions that require correction, then stand why people seek care from psythere are f'ewissues of' intellectualcon- chiatristsor some othertypeof helperis to
cern. But the inquirymay also attemptto attemptto isolate a dispositionaltraitand
probe somewhatdeeper to examine why examine its correlates and social depeople withsimilarsymptomsbehave dif- velopment. Such dispositional attributes
f'erently,
why assistance is sought during may be measured directlythroughverbal
some stages in illness ratherthan others, reports as with a measure of the proand whythe patientat a particularpointin pensityto seek medicalor psychiatriccare,
time comes to emphasize a given set of' or indirectlythrough the fact that some
symptoms. The most frequent reason individuals have sought care froma pargiven f'orseeing a doctor is the common ticular help source and others havtenot.
cold. But most people with colds do not The fact of having sought help from,for
consult doctors, and people who consult example, psychiatrists
definesthe disposidoctors because of'colds on one occasion tion,and the investigatorthenattemptsto
may not do so on another. An adequate reconstructthrough depth interviewsor
theorymust do more than explain a cer- statisticalmanipulationof surveyor other
tain proportionof'the variance in the de- data both the antecedents and conpendent variable; it must provide some comitantsofSuch dispositions.Mostof the
way of' accounting f'or the diversityof' literaturehas not gone beyond simple soresponse not onlyamong individualsand ciodemographic correlates of particular
groups but withinthe life historyof in- help-seekingpatterns,and almost no didividtuals.It is conceivable, for example, rectstudyhas been undertakenof the sothat the common cold is an excuse f'or cial developmentof differentdispositions.
visitinga physicianin contrastto the priThere are a varietyof interestingissues
marymotivation,and the desire to relieve concerning the social development of
the stress of'a hated job or an unhappy help-seeking dispositions that iremain
familysituationoften constitutesthe pri- highly problematic. For example, theire
mar-ymotivation.The implicationof'stuchi are abundant studies indicating that
a hypothesis,in contrast to the iational women repoiot.'ariotussymptoms mor-e
theoryreferredto above, is thatelimina- frequentlythan men and use medical and
tingthe prevalenceof'coldsin the popula- psyclhiatric
facilitiesmore commonly((IIItionis likelyto hlavea less di-amaticimpact rinet al., 1960; Srole et al., 1962; Dohrenon titilizationthan mightbe expected. If' wend and Dohrenwend, 1974; Cove and
the common cold as ajuistification
l)ecame Tutdor, 1973; Anderson and Anderseff,
less v'iable, people wotuld find'other ex- 1972). Many r-easonsare given by inctises to seek release f'i'omobligationsoi' vestigatorsto explain such differences:
real differencesin the preNvalence
sup port.
of psyclhologicaldisorder; characteristicsof thi
iMe'lI'/OOlgOg'('(l/ (CollsidC)'raioMiS
measturesused and judgments made of
It is often difficultto pose intei'esting disorderstiat containsex biases; women's
so thatthey'are answer'able.Al- lower threshold to perceive symptoms;
Ilulestions
396
JOURNAL OF HEALTH
AND SOCIAL
BEHAVIOR
differencesbetween men and women in fectingthe actual rate of medical utilizathe willingnessto acknowledge the pres- tion. Thus, it appeared thatstudentshad
ence of symptoms;and psychobiological differentialpredispositions to cope by
differencesbetween men and women. Al- using health services; stressappeared to
thougheach of thesevarious explanations be the triggerthat activated the disposisurfaces from time to time, few in- tion among those who were high on this
vestigatorsattemptto devise studies that variable.Stressprobablyled to othertypes
allow competing hypothesesto be tested. of coping behavior among those who had
Mechanic (1964) found in a studyof the lower dispositionsto use medical services.
socialization of attitudes toward illness Gurin and his associates (1960), in a nathatsex differencesin reportingreactions tional surveyof definitionsand reactions
to illnessand pain were already apparent to personal problems,suggested thatdifin childrenbythe fourthgrade, and these ferenttypesof factorsinfluencevarying
increased as children became older. aspectsof thehelp-seekingprocesssuch as
Aggregate data on sex and utilizationof the identification
of the problem,thedecimedical care suggest that women have sion to seek care, and the particulartype
higher levels of utilizationat all ages ex- of practitionerconsulted.
cept during childhood when it is usually
3. StudyoftheEffects
oftheStructure
ofthe
the motherwho makes decisions forboth HealthiDeliverySystem
on Utilization:Still a
boys and girls.However, Lewis (1975) has thirdapproach to studyingutilizationis to
shown that sex differences in using a examine the help-giving organizations
school health service exist even among and the extent to which they either enyoung children in an experimentalchild- courage care among certain groups or
initiated help-seeking system. A better impose barriers to such care (McKinlay
understandingof how differencesby sex, and Dutton, 1974:275-284). Barriersmay
as well as other important personal result from the location of sites of care,
characteristics, emerge requires de- economic or otherimpedimentsto access,
velopmental inquiry. It will become bureaucratic harassment,social distance
clearer, however, that defining help- between client and professional, stigma
seeking predispositionsis no easy matter associated withseekingcare, or whatever.
and involvesthe same typesof difficulties Such barriersmay furtherresultbecause
inherent in other predispositional in- of the way in which agencies and profesvestigationin developmental psychology, sionals define their work and organize
such as in the study of honesty, in- their efforts.Beginning with the early
dependence, etc.
studyof Myersand Schaffer(1954), show2. Studyof theInteraction
of Independent ing the varying accessibilityof a psyVariablesExplainingUtilization:One of the chiatricclinicto clientsof differentsocial
most common approaches to studying statuses,manystudieshave illustratedthe
help-seeking is to carry out an extent to which agencies express preferepidemiological surveyand to identifyin ences forcertaintypesof clientsand how
the survey population those who have social dissimilaritybetween clients and
sought a particular type of care. Other professionals results in difficultiesin
data fromthe surveyare then used to ex- communicationand disruptionof service.
amine how the characteristicsof those
4. Studiesof Processesof IllnessAttribuwho seek care differfrom those who do tion: An illuminating approach to the
not. Such analysis allows the exploration studyof the identification
and response to
of interactiveeffectsand more complex symptomsis the investigationof the atmodelsof help-seeking.Mechanicand Vol- tributionprocess itself,and how people
kart (1961), for example, in a study of come to make sense and give significance
freshmenstudents,found that both ten- to the experiences theyhave. One of the
dency to adopt the sick role and stress most consistentfindingsin the illnessbewere related to the use of studenthealth havior literatureis that persons are more
services.Stresswas more influential,how- likelyto take action for symptomsthatin
ever, among those studentswitha higher some fashion disrupt usual functioning
propensityto use medical servicesin af- thanin othercircumstances,and thatcon-
PERSONAL RESPONSES
TO PSYCHOLOGICAL
cepts of health are affected as much by
total functioningas by the nature of the
symptomsexperienced (Mechanic, 1968;
Hennes, 1972). Persons experiencing
changes in usual physicalfunctioningand
feeling-statesengage in various attempts
to make sense of theirexperience and test
various hypothesesabout the seriousness
of the symptomsthey are experiencing
and possiblecauses (Mechanic, 1972). The
manner in which attributionsare made
affectsthe significancegiven to symptoms
and the typesof action pursued.
One of the mostinterestingdimensions
of such attribution
processesrelevantto the
mental disorders is how people come to
attribute causality to their experiences,
and more specificallythe locus of causality. Under what conditions,for example,
do people come to view their feelingsor
behavior as a consequence of a moral failure or as a consequence of an illness for
which they are not responsible? Particularlyin cases where definitionsof mental
disorder are imposed on individuals by
othermembersof theirsocial group, decisions must be made as to the extent to
which the behavior or attitudeof the patient reflects "badness" in contrast to
"sickness,"and these attributionsare very
much affectedbythesocioculturalcontext
(Mechanic, 1968).
Attributionsof causalityhave considerable implicationsfor the care provided,
for the course of disorder,and may even
dramaticallyaffectprograms of rehabilitation. For example, during the Second
World War soldiers who experienced
"breakdown"in combatwere evacuated to
the back lines, and theirdisorganized behavior was viewed as rooted in theirearly
childhood socialization.The soldier,wishing to avoid furthercombat, readily accepted the attributionthat the problem
was rooted in his personality,and it was
difficultto returnthese soldiers to active
duty (Glass, 1958). The militarylater developed a psychiatricpolicy that defined
stressreactionsin combat as transientreactions.Although soldierswere givenopportunitiesto rest, the definitionof the
situationwas thatthiswas a reactionin the
normal range, and that soldiers were expected to returnto active duty. With this
DISORDER
397
policy,manysoldiersreturnedto effective
functioning within their units. These
policies have now been translated into
communitycare of the mentallyill, and it
is apparent that many patientssuffering
from psychologicaldistressdo extremely
well withminimalintervention.At times,
however,such policies are carried too far
and it is assumed that communitytenure
by itself, without adequate supporting
care, can allow disabled persons to functionadequately. The basic point,however,
should be clear: the manner in whichthe
behavior is conceptualized has an importantimpact not only on how the person affectedsees himselfand his effortsat
continuingcoping, but also on how he is
perceived by the communityin which he
resides.
The studyof how people come to understand and conceptualize experiential
change is perhaps thearea mostneglected
in studies of reactions and help-seeking.
Although a varietyof interviewstudies
have been carried out that attemptto reconstruct the attribution process, such
retrospectivereportsmay be closer to reconstructionsof whattook place in lightof
later experience than accurate descriptions of the attributionprocess itself.Although such studies as those of Clausen
and Yarrow (1955) provide a good intuitive sense of the processes of attribution
and normalization, by focusing on patientswe lose an understandingof those
instanceswhere behavior was normalized
and the person concerned did notbecome
a patient.Moreover,retrospectivereports
may come to emphasize the more dramatic and unusual aspects of the process,
neglectingthose more mundane aspects.
Furthermore,to the extent that the individuals involved are coping with the
problem effectivelythrough attributions
that normalize unusual feeling-states,
they may not experience consciouslythe
extentto whichtheirframesof reference
are changing. Davis (1963), in a studyof
adaptations to having a child with polio,
followedfamiliesforseveralyearsand observed that although they changed significantlyin confrontingthe crisis, they
often failed to recognize the extent to
whichtheyhad changed. Such lack of rec-
398
JOURNAL OF HEALTH
AND SOCIAL
ognition may be part of the coping process. To the extent that adaptation is
smooth and effective,one would anticipate that the actors themselves would
not fullyrecognizethe extentto whichthe
situationrequired them to change.
A Noteon Level ofAnalysis
It is frequentlyimpliedthatreactionsto
mental disorder and help-seekingare in
some waya unique topic deservingspecial
attention. Although there are some
unique aspectsto thementaldisordersarea,
at least froma descriptivevantage point,I
do not believe thatit is particularlyuseful
to dwell on such descriptivevariations.If
our concern is to develop a bettertheoretical approach to illuminatinghow reactions come about and relate to helpseeking,we mustnot neglectthe factthat
reactions to physical and psychological
changes are part of the same general attributionprocess, and that many of the
same factorsare operativewhetheritis the
person himself who is interpretinghis
or behavioror whethersuch
feeling-states
attributionsare being made by others in
the group (Mechanic, 1968). From a
help-seekingperspective,mentaldisorder
is differentfromphysicaldisorder in that
the nature of the problem,as it becomes
evident, may lead to somewhat different
scores on varying dimensions of importance.Thus, any set of symptomsmay
be evaluated by the extent to which they
disruptnormalfunctioning,theirvisibility
to others,theirperceived seriousness,the
extentto whichtheyelicitembarrassment,
the extentto whichtreatmentis perceived
as effective,
or whatever.The value on any
of these criteria may be very different
from one condition to another. Analytically, consideration of' how a particular
condition falls on relevant dimensions is
more helpful than the gross distinction
between psychiatricand nonpsychiatric
conditions. Similarly,the underlyingdimensions of' the attributionprocess are
not likelyto be verydifferentin situations
wherethe personis defininghisown problem in contrast to one where interpretationsof the problem are imposed
by others.
The problem of identifyingmentaldis-
BEHAVIOR
order is furthercompounded by the fact
thatmuch of mentaldisorderis treatedby
primary care physicians in contrast to
mentalhealthprofessionals,and thatsuch
problems are often presented to helping
personnel in physicaland psychophysical
terms (Gardner, 1970; Shepherd et al.,
1966). Thus the line betweenphysicaland
psychiatric
illnessis noteasilydefinedand,
indeed, it is often the attributionprocess
and the factorsthat affectit that determine the manner in which the symptoms
are organized and how theyare presented
to helping agencies. Certainly,the problem of understanding reactions is simplified if' analysis is limited to certain
well-definedinstancesof'mental disorder
such as schizophrenia. But from a sociological perspective, it is valuable to
studya widerspectrumof problems,since
the issue of interestis how the person
comes to identifya problem, define the
nature of the problem, and identifythe
appropriate helping source, and how he
negotiates among the various agencies
thatplay some role in providingcare. The
processof attributiontakesplace whenthe
illness situation is still unorganized (Balint,1957). To focuson more coherententitiestends to exclude the more ambiguous cases in whichthe attributionprocess
is at work, and thus misses part of the
process that is of sociological interest.
T
More SpecificIsses
In understandinghow people come to
define a problem and seek appropriate
assistance,it is necessary to distinguisha
varietyof issues in a way that no existing
studyhas effectively
achieved. In thissection I wish to specifythe issues thatmust
be disentangled, the methodological requirementsforpursuingthem,and problems of' measurement that complicate
such investigation.
Most of' the existing literaturein the
past decade demonstrates certain continuitiesin the characteristicsof individuals drawn to psychiatriccare. Existing
studies generally agree that such persons are more likelyto be of'highereducationaland income levels,of urban or suburban residence, of Jewish identification
or of' low religious participation, and
PERSONAL RESPONSES
TO PSYCHOLOGICAL
women (Gurin et al., 1960; Kadushin,
1969; Boyce and Barnes, 1966; Scheff,
1966a). At a more analyticlevel ithas been
argued thatpersonsmore inclinedto seek
psychiatriccare are more likelyto have
developed vocabularies of distress(Bart,
1968), to have a cosmopolitanorientation
(Linn, 1967), or to be partof a social circle
of others who are friendsand supporters
of psychotherapy(Kadushin, 1969). In
short, seeking care for psychiatricproblems and remaining receptive to psychotherapyhave been seen by a varietyof
students of the problem as indicativeof
being part of a subculturalmilieu that is
encouraging, supportive,and that values
the nature of the service given.
To complicate the issue, however,it is
necessaryto takeintoaccountthattypesof
treatmentare themselveslinked to social
movements,and have theirown rise and
decline over timeas the appropriate fashion for a particularsubgroup facing life
problems or existential dilemmas. Psychoanalysis, for example, developed its
roots in urban areas, with many practitioners of urban, middle-class,Jewish
origins.It is notsurprising,therefore,that
this form of therapy attracted persons
withcertain social characteristicsand life
inclinations.But as the psychotherapeutic
movementgrewand developed, itbecame
more heterogeneous in itsgeographic location and the types of practitioners
trained; and as these characteristics
changed, so did the clients drawn into
treatment.Althoughthereis no definitive
study,there is everyindicationthat both
psychotherapistsand their patients are
becoming more like the general population than was true twentyor thirtyyears
ago. Thus, the social characteristicsof
clientsdrawn to such therapies are likely
to change over time,becominglessdistinctive. The kinds of resultsresearchersare
likelyto obtain on the descriptiveaspects
of the selection of patients depend, in
part, on what point in time they take a
cross section of a continuing process
through time.
At any single point in time,several interrelated issues exist in understanding
the significance of sociocultural differencesamong patientswho seek particu-
DISORDER
399
lar types of treatment (Greenley and
Mechanic, 1975). First,it is necessary to
distinguish the extent to which social
characteristics are related to seeking
treatmentbecause theseare also relatedto
the prevalenceof certainproblemsrequiring treatment.It is notclear to whatextent
these social characteristicsare related to
the occurrence of problems or to the
care-seekingprocess. Second, it is necessaryto distinguishthe extentto whichcertain socioculturalprocesses are related to
the inclination to seek care (or dependency on helping sources) as compared with their effecton the use of a
particularsource of care. It is obvious that
Jewishidentification,although related in
manystudiesto the use of psychotherapy,
does not increase the propensityto use
Catholic counselors. Most studies in the
literatureconfusethe issue of generalized
sociocultural selection in seeking assistance for mental disorder fromthe issue
of selectionof specificformsof help.
The requirements for carryingout a
study that allows separation of sociocultural effectson symptomsas compared with seeking help, and on generalized help-seeking propensities as
compared withspecificinclinationsto use
psychiatryor some other mode of help,
are extremelydifficultto meet. First,the
researcher must have some way of
measuringunorganized psychologicaldistress or morbiditywhich can be alternativelydefined by members of a population. Unfortunately,there are no good
measures of health levels that can be applied to community populations, and
measures of generalized psychological
distress pose a varietyof additional difficulties.Second, the studymust be so organized thatthe researcherhas access to a
variety of alternative helping sources
available to the population. Some studies,
such as thosebyGurinet al. (1960), covera
wide varietyof agencies but depend on
respondentreportsas compared withverified data, and use lifetime prevalence
rates that are unreliable. Preferablyone
would like to studya population during a
defined period of risk and under conditionswhere the help-seekingbehavioris
verifiable by agency records. Further-
400
JOURNAL OF HEALTH
AND SOCIAL
more, to the extentthat the studyis concerned with issues of functioning,diagnostic assessments made by helping
practitioners,and the like,it would be desirable to obtain as much data as possible
on performance from sources independent of the respondent,and preferably fromrecords.
A furthercommentis required on measuresof psychologicaldistress.At present,
there are no adequate reliable techniques
foridentifying
psychiatricdisordersin the
general population, although a greatdeal
of progresshas been made in developinga
reliable clinicalpresent-stateexamination
with patient populations (Wing, 1974).
Existing measures such as the Langner
22-item scale and the Health Opinion
Survey, based on items from the Army
Neuropsychiatry Inventory, confound
physicaland psychiatricdistressand are
biased by problems of social desirability
response (Dohrenwend and Dohrenwend, 1969; Crandell and Dohrenwend,
1967; Seiler, 1973; Manis et al., 1963;
Tousignant et al., 1974; Phillips and
Clancy, 1970; Dohrenwend et al., 1970).
Because of the association between age
and physicalmorbidity,
such measuresare
particularlydeceptive when comparing
subgroups of varyingages. Similarly,in
populations of considerable ethnic and
cultural heterogeneity,social desirability
may be a source of major biases. Such
measures, however,may stillbe relatively
usefulin studyingpopulations withinlimited age ranges and that-arenot too culturally diverse. In any case, they offer
better solutions than the one most sociological studies adopt - completelyexcluding the measurement of mental
health status.
The ideal approach, although usually
impossible to implement and extremely
expensive, would be to followon a panel
basis a large defined population withaccess to a definable range of helping services. Althoughcomplete controlis never
fullypossible,opportunitiesfora successful study are increased in a closed panel
healthcare plan, particularlyone in a relatively isolated community where treatmentalternativesare not readilyavailable
or are easilyidentifiable,and thus can be
BEHAVIOR
included in the study. Other alternatives
include such self-containedgroups as college communities, armed forces units,
ships,smallisolated communities,and the
like. Such a study could monitor the occurrenceof distressin the population,the
processes by which people identifyand
make sense of unorganized symptoms,
and typesof help-seekingfromalternative
agencies available to the population, such
as medical care, mental health practitioners,clergymen,lawyers,special clinics,etc.
To the extent that such a study would
monitorthe help sources themselvesand
the course of treatment,it becomes possible to separate not only the issues already
identified,but also to ascertain whether
the factorsthat facilitatecontinuationin
treatmentare separable fromthose leading to the initiationof treatmentin the
firstplace (Levinger, 1960).
of implementThe cost and difficulties
ing such a methodology require some
compromises. One possibility that has
been used in a varietyof studiesis to compare a random sample of a defined population eligible to use a particularfacility
with a sample of users (Scheff, 1966a;
Linn, 1967; Greenley and Mechanic,
1975). Althoughone cannot demonstrate
a causal sequence using such a methodology, a varietyof interestinghypotheses
can be examined. Greenleyand Mechanic
(1975), using such an approach, compared a random sample of a defined
population withsamples of users of various helping agencies which the population was eligible to use. However, in the
case of the random sample, furtherdata
wereobtainedon the use of a widervariety
of agencies includingthose forwhichspecial samples were obtained. If the random
sample is large,theavailabilityof reported
data on help-seeking allows the replication of the analysis within the random
sample thatwas carried out across agency
samples. To the extent that comparable
results appear, there is reason to have
added confidence in the findings.The
value of workingwitha varietyof alternative agencies is the availabilityof data independent of reportsby respondentsand
the possibilityof examining sociocultural
influenceson help-seekingin general as
PERSONAL RESPONSES
TO PSYCHOLOGICAL
DISORDER
401
compared withinclinationsto use particu- These studies do not make clear whether
lar typesof helpers.
sex is important primarilybecause it is
related to rates of symptomatologyor
The StateoftheLiterature
whetherit has an independent effecton
Most of the existing literature docu- help-seekingbehavior. Similarly,the high
ments with considerable consistencysys- proportion of Jews found in psytematic differencesin the sociocultural chotherapyhas been said to resultfroma
characteristicsof users of particularhelp- high level of introspection(presumably
ing facilities.Only a few studies tangle making feeling-statesmore salient and
withthe kinds of theoreticalissues I have heighteningdistress)(Henry et al., 1968),
suggested. Kadushin (1969) has perhaps or greater willingnessof Jews to express
done the mostextensiveworkon attempt- distressand seek assistance (Antonovsky,
ing to describe how individuals come to 1972). Few studies differentiatethese
perceive that they have a problem, the factors.
nature of the problem, whether care
Scheff(1 966a) was one among veryfew
should be sought,and what typeof prac- investigatorswho attempted to measure
titionerto consult. He analyzes the pro- psychological problems as intervening
pensityto use certaintypesof servicesin variables,basing the measure on a probtermsof his concept of social circles and lem listdeveloped from presentingcomindicates thatwhile those of highersocial plaintsof studentswhen theysought help
statusand of low religiosity
tend to consult from a psychiatricclinic. Scheff found
analyticclinics,lower status persons and that,although the clients' problem levels
those more religious are drawn to were related to seeking help, the soreligious-based
counseling
clinics. ciocultural differences persisted when
Kadushin (1962) has further provided number of problems was controlled. He
support for the hypothesisthat patients found, however, that sociocultural setend to seek among alternative helpers lectivitywas greateramong studentswith
those that minimize social distance be- feweras compared with more problems.
tween patient and therapist.
One of the difficultieswithScheff'smeaAlthough studies by both Scheff sure was the absence of any indication.of
(1966a) and Linn (1967) are confinedonly severityother than the number of probto use of psychiatricservices,theypresent lems reported.
analyses verysimilarto the one provided
Greenley and Mechanic (1975) have
by Kadushin (1969). Scheffinfersa sub- carried out an extensive epidemiological
cultureattunedto psychiatry
on thebasisof surveyas well as a studyof studentsusing
sociocultural characteristicsdifferentia- particularhelpingagencies in order to extingusers fromthe populationfromwhich amine some of the issues describedin this
theycome. Linn (1967), studyingthesame paper. Althoughtheyused a wide variety
clinic,more directlymeasures culturalat- of indicators to measure level of psytitudes and associations withothers, and chological distress,and took severityinto
suggeststhatthereis a cosmopolitansub- account, they find, as do other inculturecharacterizedbyintrospection,in- vestigators(Langner et al., 1963; Gersten
terest in psychology,and the like, that et al., 1974), thatsimplecountingof symppredisposes individualsto use psychiatric tomsor problemsgivesresultscomparable
services.
to more detailed scaling of severity.The
The literatureis particularlyconfusing comparabilityof findingsis probablydue
in differentiating
socioculturalcharacter- to the factthatrespondentswho are more
tisticsas theyaffectthe occurrenceor rec- seriouslydistressedare likelyto report a
ognitionof distressin contrastto theiref- larger number of problems.
fect on the use of helping services. For
Using the Langner (1962) scale as a
example, epidemiological investigations measure of psychologicaldistress,Greenfindthatwomen reportmoredistressthan ley and Mechanic could account for very
men; help-seekingstudies also find that littlevariance in rates of distresson the
women use more services than men.. basis of social and culturalcharacteristics
402
JOURNAL OF HEALTH
AND SOCIAL
of students. Only sex and age had any
importanteffects.They found, however,
considerable sociocultural selectivityin
the use of psychiatricservices consistent
withmanyotherstudies:in the psychiatric
sample there was an overrepresentation
of women, older students,studentswith
Jewish identification or no religious
affiliation,those fromfamiliesof high socioeconomic status, and the like. However, those studentswho used a student
counseling service had different and
sometimesopposite characteristics.Thus,
students coming to counseling were
youngeron the average than the students
in the population fromwhichtheycame.
Only the overrepresentationof women
was consistentwithselectioninto the psychiatricclinic. Similarly,theyfound considerable specificselectionintoa varietyof
formalhelpingsources withinthe random
sample suggestingthatmuch of the social
selection into care depends on certain
compatibilitiesbetween help-seeker and
help-provider.The informationon use of
a varietyof' formal help-givingagencies,
including psychiatrists,counselors, clergymen,general physicians,and the like,
allowed them to compare students who
sought help froma formalhelper as compared withthose who did not. When such
an analysisis performedthereis verylittle
differenceon the basis of' sociocultural
characteristicsbetween these two groups,
suggestingthat most SuLCh clharacteristics
have littlerelationshipto a general readiness to seek help for personal problems.
There are a few other findingsworthy
of note here. Tlhe most importantsingle
factoraffectingthe use of' psychiatryor
counseling servicesis the level of'distress.
thereis significantsociocultural
Altlhotuglh
selection,it operates for the most part independentlyof'distresslevels.Of the variotissocioculturalfactors,onlysex appeal-s
to be related in any significantfashion
both to the reportingof levels of'distress
Handto the use of' helping services.While
controllingfor distressseems to account
for the overrepresentationof' women in
the psycliat-ry
sample, stuclccontrolsdid
not account for theoverrepresentationof
women in the counseling sample or the
overrepresentationof'women in the ran-
BEHAVIOR
dom sample reportingconsultinga psychiatrist. Although Greenley and
Mechanic found a slighttendencyforsocial selectionto be strongestamong those
least impaired, for the most part social
selection appeared to operate in a comparable way at varyinglevels of distress.
Finally, they found that distress played
some role in the selection among formal
help sources. In general,studentsseeking
care from psychiatryas compared with
othersources of help had higherlevelsof'
reported distress.
WhereDo We Go FromHere?
The discussion has ranged over a wide
area, suggestinga varietyof issues that
remain to be clarifiedabout how people
respond to indicationsof mentaldisorder.
I have neglected the literatureon otherdefined deviance, as in the case of involuntaryhospitalization,since these issues have been amplydiscussed elsewhere
(Mechanic, 1968; 1969), and growingemphasis in society- as well as in research
is being devoted to voluntary
studies
processesof care. I should emphasize that
many of' the considerationshere are applicable to "other-definedsituations,"and
the neglect of' specificdiscussion should
notsuggestthatthisarea offersno further
provocativequestions for the sociologist.
The shift away from involuntaryhospitalization and the emphasis on communitycare, as well as the new emphasis
on the rightsof the mentallyill,is partof'a
social movementthatis likelyto be cyclical
in its development. Already there are
strong indications of a community
backlash to permissivemental health applications,and forcesare growingto reinstate at least partiallysome earlier practices.The politicsof the mentalhealthsector have been very poorly studied and
require vigorotussociological analysis.
In pursuing fur-ther
research, the following general frame of' reference appears to be a viable startingpoint. The
occurrence of symptoms, partictularly
when theybecome visible,disr-iuptive,
or
incapacitatingin some fiashion,set into
motion a process of co rceptualizationin
whichvariotusattributionsare made. The
natture
of'theattributionprocessis to some
-
PERSONAL RESPONSES
TO PSYCHOLOGICAL
extentshaped by the characterand magnitude of the symptomsbut also by the
socioculturalcharacteristics
of'thepersons
and the social circles within which they
function. The type of' care selected depends on sociocultural predispositions,
the assessmentof'the locus of causalityof
the problem, the immediate social context,and the characterand accessibilityof'
available helping services.In all probability,whenconditionsare ripe,anyof a wide
variety of triggering events may help
bringindividualsto a source of'help. Such
triggersmay include certain crises they
confrontbecause of' this problem, social
influencesof'significantothers,or public
informationthatgivesthemcues as to the
availabilityof a source of help well fitted
to their difficulty.Future effortswill be
required to provide data to clarifythe
frameworkand furtherextend it.
DISORDER
403
Dinitz, S., et al.
1962 "Instrumentalrole expectationsand posthospitalperformanceof'femalementalpatients."Social Forces 40 (March): 248-254.
Dohrenwend, B.P., and B.S. Dohrenwend.
1969 Social Status and Psychological Disorder.
New York: Wiley-Interscience.
1974 "Social and cultural influences on psychopathology." Annual Review of' Psychology 25: 417-452.
Dohrenwend, B.P., et al.
1970 "Measures of' psychiatricdisorder in contrastingclass and ethnic groups: A preliminaryreport of' ongoing research." 1'.
179 in E.H. Hare and J.K. Wing (eds.) Psychiatric Epidemiology: An International
Symposium. London: Oxf'ord University
Press.
Freeman, H., and 0. Simmons.
1963 The Mental Patient Comes Home. New
York: John Wiley.
Gardner, E.
1970 "Emotional problems in medical practice."
Annals of'InternalMedicine 73 (October):
651-652.
Gersten,J.C., et al.
1974 "Child behavior and lifeevents: undesirable changeor change per se?" Pp. 159-170in
REFERENCES
B.S. Dohrenwend and B.P. Dohrenwend
Life Events: Their Nature
(eds.) Stressfutl
Anderson, Odin, and Ronald Andersen.
and Effect.New York: John Wiley.
1972 "Patterns of use of' health services." Pp. Glass, A.J.
386-406 in Howard Freeman et al. (eds.)
1958 "Observations upon the epidemiology of'
Ha-ndbook of Medical Sociology. Second
mental illness in troops during warf'are."
Edition. Englewood Cliffs:Prentice-Hall.
P'p. 185-206 in Symposiumon Preventive
Antonovsky,A.
and Social P'sychiatry.
Washington,D.C.:
1972 "A model to explain visitsto the doctor:
Walter Reed Army Instituteof' Resear'ch.
with specificreferenceto Israel." Journal Gove, W.R., and J.F. Tudor.
of' Health and Social Behavior 13 (De1973 "Adult sex r'oles and mental illness."
cember): 446-454.
Amer'ican Journal of' Sociology 78
Balint, M.
(Januiary):812-835.
1957 The Doctor, His Patient,and the Illness. Greenley,J., and D. Mechanic.
New York: International Universities
1975 "llatternsof'seekingcarle forpsychological
Press.
problems." Putibl.16-74, Research and
Bart, P).
Analytic Series, Centel f1orMedical So1968 "Social structureand vocabularies of' disciology an-id Health Services Research.
cornforwt:what happened to female hysMadison: L'niversityof'Wisconsin.
teria." Journal of' Health and Social Be- (;iiri-M,G., J. \erolf, an-idS. Feld.
havior 9 (September): 188-193.
196() Americans View Their Mental Healtlh.
Boyce, R.M., and D.S. Barines.
New York: Basic Books.
1966 "Psychiatric p)rolblemis
of universitystI- f[Ien
nes, J.D.
dents." Canadian PsychiatricAssociation
1972 "The meastiuremi-entof' health." Medical
Care Review 29: 1268-1288.
Journal I I ( Februar'y):49-56.
Brown, G.B., et al.
Henry, W.E., J.fH.Sims, and S.L. Spr'ay.
1966 Schizophreniaani-dSocial Care. New York:
1968 l'Pulic an-id Private Lives of P'syOxf'ord UniversityPress.
clother.apists.SaiinFiancisco: Jossey-Bass.
Clatusen,J., and M. R.C. Yarrowv.
Hollingshead, A., and R.C. Redlicl.
1955 "Paths to the mental hospital."Journal of'
1958 Social Class an-idMental Illness. New York:
Social Issues I I (October): 25-32.
John Wiley.
Cran-dell,D.1.., and B.lP. Dolhrenwend.
ladlishlin,(C.
1967 "Soine relatiouisamong p)syclhiatric
I1962 "Social distance betweenclientanldprofessymptoills, organic ililness ail social class."
Jouinralof'Sociology 67
sion-al."Anmericain
AiXierican jouriial of' Psychiatry 123
(Marclh):517-531.
I 969 Whyv
(June): 1527-1538.
New York:
People Go to P)sychiatriists.
Davis, I-.
Athlietton.
I 963 Passage Tl rough Crisis. I ndliaapolis:
I .aigner, T'S.
Bobbs-Merrill.
19(62 "A twenity-two
itcm
ilsclreeilngscoe Cof')Sy-
404
JOURNAL OF HEALTH
AND SOCIAL
chiatricsymptomsindicatingimpairment."
Journal of Health and Human Behavior 3
(Winter): 269-276.
Langner, T.S., et al.
1963 Life Stress and Mental Health: The Midtown Manhattan Study. New York: Free
Press.
Lemert, E.
1951 Social Pathology.New York: McGraw-Hill.
Levinger, G.
1960 "Continuance in caseworkand other helping relationships:A reviewof current research." Social Work 5 (July):40-51.
Lewis, C.
1975 Child Initiated Care: A Study of the Determinantsof the Illness Behavior of Children. Unpublished report. Center for
Health Sciences. Los Angeles: University
of California.
Linn, L.S.
1967 "Social characteristicsand social interactionin the utilizationof a psychiatricoutpatientclinic."Journal of Health and Social
Behavior 8 (March): 3-14.
Manis, J., M. Brawer, C.L. Hunt, and L. Kercher.
1963 "Validatinga mental health scale." American Sociological Review 28 (February):
108-116.
Matza, D.
1969 Becoming Deviant. Englewood Cliffs:
Prentice-Hall.
McKinlay,J.B., and D. Dutton.
1974 "Social-psychological factors affecting
healthserviceutilization."Pp. 251-303 in S.
Mushkin (ed.) Consumer Incentives for
Health Care. New York: Prodist.
Mechanic, D.
1964 "The influence of mothers on their children's health attitudesand behavior." Pediatrics33 (March): 444-453.
1968 Medical Sociology: A Selective View. New
York: Free Press.
1969 Mental Health and Social Policy. New
York: Prentice-Hall.
1972 "Social psychologic factors affectingthe
BEHAVIOR
presentation of bodily complaints." New
England Journal of Medicine 286 (May):
1132-1139.
Mechanic, D., and E.H. Volkart.
1961 "Stress,illnessbehavior and the sick role."
American Sociological Review 26 (February): 51-58.
Myers,J.K., and L. Schaffer.
and psychiatricprac1954 "Social stratification
tice: a study of an out-patient clinic."
American Sociological Review 19 (June):
307-310.
Phillips,D.L., and K.J. Clancy.
1970 "Response biases in fieldstudies.bfmental
illness." American Sociological Review 35
(June): 503-515.
Scheff,T.J.
1966a "Users and non-users of a student psychiatricclinic."Journal of Health and Social Behavior 7 (Summer): 114-121.
1966b Being Mentally111:A Sociological Theory.
Chicago: Aldine.
Seiler, L.H.
1973 "The 22-itemscale used in fieldstudies of
mental illness: A question of method, a
question of substance, and a question of
theory."Journal of Health and Social Behavior 14 (September): 252-264.
Shepherd, M., et al.
1966 Psychiatric Illness in General Practice.
London: Oxford UniversityPress.
Srole, L., T.S. Langner, S.T. Michael, M.K. Opler,
and T.A.C. Rennie.
1962 Mental Health in the Metropolis:The Midtown Manhattan Study. New York:
McGraw-Hill.
Tousignant, M., G. Denis, and R. Lachapelle.
1974 "Some considerationsconcerningthevalidityand use of the health opinion survey."
Journal of Health and Social Behavior 15
(September): 241-252.
Wing,J.,J.E. Cooper, and N. Sartorius.
1974 The Measurement and Classificationof
PsychiatricSymptoms. Cambridge: Cambridge UniversityPress.