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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 Stable URL: http://www.jstor.org/stable/2136611 . Accessed: 04/08/2011 17:45 Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected]. American Sociological Association is collaborating with JSTOR to digitize, preserve and extend access to Journal of Health and Social Behavior. http://www.jstor.org 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. 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