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Socio-Cultural Roots of Emotional Illness
Socio-Cultural Roots of Emotional Illness MARVIN K. OPLER, Ph.D.
• We are discussing anxiety and depression in this Symposium presumably because they are sick states the physician is called upon to treat. Whether the doctor regards this as his primary charge as a psychiatrist, or whether he is an internist who encounters such complications, the fact is that modern communities contain many persons who suffer from emotional illness in one form or another. As a principal investigator of the Cornell Department of Psychiatry's Midtown Manhattan Community Mental Health Research Study, I can report that 80 per cent of a population in the largest city in the United States suffered from some degree of impairment in life functioning which might be called "Emotional Disability." These impairments ranged in a continuum from mild and moderate disabilities on the one hand ("mild symptom formation" in 36.3 per cent of the population. and "moderate symptom formation" in 21.8 per cent) to the astoundingly high percentage of 2.1.4 pCI' cent showing marked, severe or incapacitating impairments. This last figure doubles previous estimates, using less exacting methods, in Boston and Baltimore surveys. Our study in :'\ew York City evoked front page headlines in such papers as the NelV Yark Times and Herald Tribune when our first volume of the three-volume series of hooks appeared. The first book, Melltal Health ill the Metropolis (TI/C !llidtown M all"attan Study), is less full of surprises than one might expect if one considered the fact that half of all hospital beds in the United States have for some time been devoted to psychiatric patients. Or looked at another way, we would expect in an epidemiological survey of a total population such grand totals Presented at the Symposium on Anxiety and Depression, Atlantic City, N. J., June 15, 1963. Doctor Opler is professor of Social Psychiatry, Department of Psychiatry, State University of New York at Buffalo, School of Medicine, Buffalo 14, New York. .Ianuary-Fehruary. 1964
as 80 per cent if a survey of all non-psychological organic impairments were attempted. As it is for organic impairments from mild ones to totally incapacitating ones, so it is, apparently, for emotional illness in its various dimensions. As to whether one wishes to use an 80 per cent figure, or the still shocking figure of 23.4 per cent, this depends on whether one is concerned about mild impairments as well as those labeled "marked symptom formation," "severe impairments" or "incapacitating" ones. While some newspapers chose to emphasize that one person out of every five was designated as "mentally well" and went on to report the social and cultural distributions of illness, others chose the comparable 80 per cent rate, that is comparable to a figure for all organic ailments, as a rate of some degree of disability. An earlier paper which I published under the title of "Epidemiological Studies of Mental Illness" in the U. S. government's Walter Reed Army Institute Symposium on Preventive and Social Psychiatry stressed that total epidemiology is important in assessing the range of emotional impairments. If one wished to stop at those who are impaired but in treatment, one could do a study of the simple sort of prevalence, the prevalence of those in treatment such as was done by Hollingshead and Redlich. If one wished to designate the impaired in the community, both those in treatment and those never treated, one could use the 23.4 per cent figure. But if one wished to face up to the total preventive and social tasks of medicine and psychiatry, no doubt the 80 per cent figure is our most honest and humane estimate. In this account of the Midtown findings in epidemiology, we have used two concepts that are central to our approach. The first is the notion of a continuum from well, through mild and moderate dishlrbances, reaching finally to "marked symptom formation," "severely impaired" and finally, "incapacitated." 55
PSYCHOSOMATICS
In New York City, we found people who had never been known to psychiatry or psychological medicine who were as utterly incapacitated as any I have ever seen in chronic wards. Further, the rates for impairment in general and for extreme degrees of impairment also, were not randomly distributed in the population. Both lower class and certain poorly estahlished ethnic communities, the Puerto Hican and the Hungarian specifically, had greater impairments in general, or extent of therapy-need, and more than their proportionate share of the seriolls categories of disturhance in addition, In the 23.4 per cent figure, we pointed out that 13.2 per cent showed marked symptom formation, 7,5 pel' cent exhihited severe symptom formation, and 2.7 per cent were virtually incapacitated. Such total proportions for the community as a whole are raised, not lowered, when one considers the comhination of lower social class and certain ethnic groupings such as Puerto Hican and Hungarian. In his studies of hospital admissions by class and ethnic group, Dr. Benjamin Malzherg reaches the same conclusions when, for example, he finds that Puerto Hicans have higher representation than their numbers warrant in the population of New York State for hospital admissions laheled schizophrenic. While hospital admissions data have their limitations, our epidemiological survey of community samples supports Malzberg's contentions. In medical sociology, as a matter of fact, ethnic and social class variations are being constantly discovered in organic illnesses which no one claims are psychological in origin. A colleague of mine in Buffalo, writing on "Social Factors in Helation to the Chronic Illnesses," in the Handbook of Medical Sociology edited by H. E. Freeman, S. Levine and L. G. Heeder, comments chiefly on studies of cancer and of hypertension to this effect. Dr. Saxon Graham notes class and ethnic variations in such instances. In other words, social conditionings affecting behavior may involve cultural group or class group in hiologically pathogenic functioning. One could say, all the more, that in illnesses which are emotional and have a psychological intervening variable between culture on the one hand and personality functioning on the other, the illnesses are bound to have social and cuI· 56
tural roots in the final analysis. In the Midtown Manhattan studies, 75 per cent of the total population showed high ratings on an anxiety scale or dimension. We hasten to add that this is a global assessment which technically does not discriminate between such clinical types as anxiety neurosis and depressive states in which anxiety is prominent. However, when we did gather data on such clearly defined clinical entities as psychosomatic disorders, class and cultural variables were again prominent. In the Midtown Manhattan Study, conducted with Dr. T. A. C. Hennie at the Cornell University Medical College Department of Psychiatry, we reviewed with each community respondent a series of ten somatic disorders often assigned a psychogenic basis. These included rheumatoid arthritis, asthma, colitis, allergies, stomach ulcer, essential hypertension, and diabetes. While Hillehoe and Larimore report that over 2 per cent of American adults are affiicted with diabetes, our own findings for population strata from ages 20 to 59 was only 1 per cent, with perc~ntages of 19.4 for arthritis, 9.4 for essential hypertension, 5.3 for colitis, 4.5 for stomach ulcer, and 4.4 for asthma. The pattern of prevalence for diabetes, however, was interesting, since it increased with progressively lower social sb'ata. Social status was analyzed from the points of view of education, housing and parental occupation and income. The pattern for diabetes of finding the disorder most frequently in low-status groups, shared with essential hypertension and rheumatoid arthritis, accorded well with the belief that diabetes relates to certain ways of handling life stress. The prevalence of colitis, on the other hand, decreased with progressively lower social status, while asthma was found most prevalent at the extremes of social level. However, diabetics and ulcer patients had only medium-high scores on tension-anxiety scales relating to restlessness, nervousness, sleep disturbances and overt worries that get one "down physically," suggesting relatively passive adaptations. This they shared with ulcer patients. By contrast, asthmatics and victims of hypertension had low tensionanxiety scores suggestive of a conversion or hysteriform mechanism, whereas skin disorders, colitis, and rheumatoid arthritis corVolume V
SOCIO·CULTURAL ROOTS OF EMOTIONAL ILLNESS-OPLER
related well with high scorers on tensionanxiety scales and implied a group with more direct somatization of their problems. "'hen we commented on the Midtown Manhattan Study, and noted that diabetes increases in prevalence with progressively lower social strata, we might have added that such strata derived predominantly from immigrant and second-generation Italian, Czech, Hungarian, German and Irish communities, and that some, like the Italian for example were mainly second-generation. One has then a class component made up of ethnic components. As early as 1945, Calabresi found differences in the prevalence rates of diabetes in various ethnic groups-as a matter of fact -among Italian, Poles, Germans, and Irish, in the United States. Refining this approach in a study of several generations of much the same ethnic groups in Butler County, Pennsylvania, Graham found that diabetes (and exactly as in Midtown Manhattan, also rheumatoid arthritis and essential hypertension) showed relatively low rates in the first or immigrant generation, but sharp increases among their descendants of the second generation, this being followed by declines in rates in third and sequential generation levels. These rates of diabetes were, respectively, 12 per 1,000 for the first or immigrant generation level, 22.2 per 1,000 for the second, which is almost a doubling of rate, and 12.3 per 1,000 for generations third or over. Such rates were. of course, for a standardized age and sex composition. Graham's conclusions are like ours for the Midtown Manhattan Study. namely, that immigrant generations will themselves show better mental health status, including psychosomatic rates, than their children of the second generation. The latter arc involved, as we hypothesized for Midtown lvfanhattan, in socio-cultural strains enveloping personal stresses since parental and child values (one's parents versus ones of a peer group of age mates) stand in conflict. The concept of a continuum from well to ill in every society and culture means that "impainnent in life functioning" will vary as to types of disease and quantity of impairment in each cultural group. In 1956, in a hook titled Culture, Psychiatry and H'I/1UIIl Values, the two conceptions of "impairment in life functioning" and a cultural theory of its January-Fpbmary, 1964
epidemiology were developed. In that book, the present author surveyed mental health epidemiology through several reports from cultures around the world. Mental illnesses were found to vary both in type and in amount, or in prevalence and incidence of the disturbances, on every continent for which there were clear data. Not only that, but in Western European psychiatry, diseases had changed in type and in amount. The result was that the book postulated a relational theory of social psychiatry stating that both the forms of mental illness and the amount of disturbance vary with the cultural milieu both historically in our own tradition, and crossculturally when we compare one culture with another. The book published in 1956 was written hy the present author. In 1959, however, I published another volume called Culture and Mental Health: Cross-Cultural Studies for which I furnished only two cultural studies, but for which as editor, we gathered full contemporary studies from every continent. Thc strategy was to see whether the relational theory of 1956 held good according to the work of contemporary scholars, persons in behavioral sciences who were professional psychiatrists, epidemiologists, anthropologists. sociologists and psychologists. The relational theory, that is, the hypothesis that culture determines form of emotional illness and its quantity was again confirmed, in this instance hy 23 authors representing the above disciplines and for the most part working independently and in different continental settings. This theory, now partly confirmed, stands in sharp contrast to the ideas of Thomas Szasz in his hook, The Myth of Mental Illness. Further, the Midtown Manhattan Study first volume, puhlished in 1962, fully supports the relational theory. Both the theory and the Midtown Study state that mental illnesses, far from heing a myth or a game played by practitioners and actors, are realities, in fact widespread and probably increasing realities. Szasz holds that sympathy arousal is the ess('nce of the illness game or myth. In reality. we find that illness is the kind of malfune tioning and actual impairment in life funetioning that destroys freedom and spontaneity. In 1956, further, in our first formulation of this opposite theory to that of Doctor Szasz, we
.,7
PSYCHOSO~IA TICS
predicted that such disorders as afflict modern man are probably on the increase. We pointed out that people in preliterate cultures suffering from conversion hysterias are frequently helped by the shaman and by an abundance of community supports in {'motional crises; but that modern man, freed for the most part from conversion hysteria and simple "nuclear" forms of the schizophrenias was now open to psychosomatic disorders, deepset schizophrenias with paranoid reaction, or equally devastating affective disorders. These observations on changes in types of disorders, taken together with Midtown Manhattan epidemiology should disabuse us of the false 1I0tion that mental illness is a myth-a professionally kept secret. ~1y opposing formulation is that mental illness. now proven to he more widespread than we ever imagined hefore, is a social reality. As such, it becomes a moral problem that Dr. Szasz theoretically avoids or dismisses. The prohahle increases in psychosomatic disorders and in more profoulld forms of schizophrenias stand in contrast to such small counts of mental illnesses as Dr. M. E. Spiro divulged for the ~1icr01wsiall culture of Haluk in mv hook. Cultur(' (/1/(1 :\I ental Jlmlth. The'statistics 011 mental ht'alth in such cross-cultural surveys contrast markedly to very serious disorders in our Midtown Manhattan survey. The issue is 110 longer whether culture influences mental Iwalth epidemiology, hut rather. hou; does culture help or harm in each milieu. Freud's phrase for heing "thrust into conflict" in his work on group psychology may now he rephrased into the question: "'hat are the conditions for heing thrust into conflict. or how does personality impairment and disintegration occur? \Ve are today closer to the answers. Oviously. what Fr~'ud phrased as the
"conditions for conflict," we must, in social psychiatry, rephrase as the social conditions for conHict, for impairment, or for personality disintegration. In these formulations of social psychiatry, much has been published since 1955 in our Intemational Journal of Social Psychiatry
rounding out the picture of such conditions of existence. Our position is obviously evolutionist on a social level, as Freud's was on an individual maturational level. As evolutionists. we do not believe in an absolute relativism, hut rather, that human adaptations are to social and cultural scenes. The hope is that change in the future, informed by the findings of social psychiatry, can restore freedom and spontaneity to the prohable half of all those with illnesses today having psychological and social roots. REFERENCES
I. Freeman, H. E., Levine, S., and Reeder. L. G.
:!.
3.
4. 5.
6.
7.
H.
(Eds.): Handbook of Medical Sociology. Nf'W York: Prentice-Hall. 1963. Graham, Saxon: Ethnic hackground and illness in a Pt'nnsylvania county. Soc. Prnhlems, 4:76-82 (July) 19.56. Opler, M. K.: Culture, Psychiatr!l and Humau Value.~. Springfield, III.: Chas. C Thomas, 1956. Opler, M. K. (Ed.): Culture and Mental Health; Cross-Cultural Studies. New York: Macmillan Co., 1959. Opler, M. K.: Epidemiological studies of mental illness: methods and scope of the Midtown Study in New York. In Symposium on Preventive and Social Psychiatry. Washington, D. C.: WaltN Reed Army Institute of Research. 195R. Spiro, M. E.: Cultural heritage, personal tensilms, and mental illness in a South Sea culture. In Culture and Mental Health (edited by ~1. K. Opler). New York: Macmillan Co., 1959. Srole, L., Langner, T .. Michael, S., Opler, M. K.. and Rennie, T. A. C.: Mental Health in the .\tetropolis: The Midtown Manhattan Study. ~ew York: \fcGra\\'-HiII Co., 1962. Szasz. T. S.: The .\Iyth of Mental lll,l('s.~. ~l'\\' York: Hoeher-Harper Co., 1961.
It is natural that th(' individual sees only what he comprehends, and that he comprehends only what in his opinion ('onc('ms him. '\. H .... IITM .... SN. Quoted by Eugen Kahn in Theories of the \lind. Edited hy Jordan Scher, \I.D., The Fret' Press of Glencoe, ;'II. Y.
58
Volume \'
• We are discussing anxiety and depression in this Symposium presumably because they are sick states the physician is called upon to treat. Whether the doctor regards this as his primary charge as a psychiatrist, or whether he is an internist who encounters such complications, the fact is that modern communities contain many persons who suffer from emotional illness in one form or another. As a principal investigator of the Cornell Department of Psychiatry's Midtown Manhattan Community Mental Health Research Study, I can report that 80 per cent of a population in the largest city in the United States suffered from some degree of impairment in life functioning which might be called "Emotional Disability." These impairments ranged in a continuum from mild and moderate disabilities on the one hand ("mild symptom formation" in 36.3 per cent of the population. and "moderate symptom formation" in 21.8 per cent) to the astoundingly high percentage of 2.1.4 pCI' cent showing marked, severe or incapacitating impairments. This last figure doubles previous estimates, using less exacting methods, in Boston and Baltimore surveys. Our study in :'\ew York City evoked front page headlines in such papers as the NelV Yark Times and Herald Tribune when our first volume of the three-volume series of hooks appeared. The first book, Melltal Health ill the Metropolis (TI/C !llidtown M all"attan Study), is less full of surprises than one might expect if one considered the fact that half of all hospital beds in the United States have for some time been devoted to psychiatric patients. Or looked at another way, we would expect in an epidemiological survey of a total population such grand totals Presented at the Symposium on Anxiety and Depression, Atlantic City, N. J., June 15, 1963. Doctor Opler is professor of Social Psychiatry, Department of Psychiatry, State University of New York at Buffalo, School of Medicine, Buffalo 14, New York. .Ianuary-Fehruary. 1964
as 80 per cent if a survey of all non-psychological organic impairments were attempted. As it is for organic impairments from mild ones to totally incapacitating ones, so it is, apparently, for emotional illness in its various dimensions. As to whether one wishes to use an 80 per cent figure, or the still shocking figure of 23.4 per cent, this depends on whether one is concerned about mild impairments as well as those labeled "marked symptom formation," "severe impairments" or "incapacitating" ones. While some newspapers chose to emphasize that one person out of every five was designated as "mentally well" and went on to report the social and cultural distributions of illness, others chose the comparable 80 per cent rate, that is comparable to a figure for all organic ailments, as a rate of some degree of disability. An earlier paper which I published under the title of "Epidemiological Studies of Mental Illness" in the U. S. government's Walter Reed Army Institute Symposium on Preventive and Social Psychiatry stressed that total epidemiology is important in assessing the range of emotional impairments. If one wished to stop at those who are impaired but in treatment, one could do a study of the simple sort of prevalence, the prevalence of those in treatment such as was done by Hollingshead and Redlich. If one wished to designate the impaired in the community, both those in treatment and those never treated, one could use the 23.4 per cent figure. But if one wished to face up to the total preventive and social tasks of medicine and psychiatry, no doubt the 80 per cent figure is our most honest and humane estimate. In this account of the Midtown findings in epidemiology, we have used two concepts that are central to our approach. The first is the notion of a continuum from well, through mild and moderate dishlrbances, reaching finally to "marked symptom formation," "severely impaired" and finally, "incapacitated." 55
PSYCHOSOMATICS
In New York City, we found people who had never been known to psychiatry or psychological medicine who were as utterly incapacitated as any I have ever seen in chronic wards. Further, the rates for impairment in general and for extreme degrees of impairment also, were not randomly distributed in the population. Both lower class and certain poorly estahlished ethnic communities, the Puerto Hican and the Hungarian specifically, had greater impairments in general, or extent of therapy-need, and more than their proportionate share of the seriolls categories of disturhance in addition, In the 23.4 per cent figure, we pointed out that 13.2 per cent showed marked symptom formation, 7,5 pel' cent exhihited severe symptom formation, and 2.7 per cent were virtually incapacitated. Such total proportions for the community as a whole are raised, not lowered, when one considers the comhination of lower social class and certain ethnic groupings such as Puerto Hican and Hungarian. In his studies of hospital admissions by class and ethnic group, Dr. Benjamin Malzherg reaches the same conclusions when, for example, he finds that Puerto Hicans have higher representation than their numbers warrant in the population of New York State for hospital admissions laheled schizophrenic. While hospital admissions data have their limitations, our epidemiological survey of community samples supports Malzberg's contentions. In medical sociology, as a matter of fact, ethnic and social class variations are being constantly discovered in organic illnesses which no one claims are psychological in origin. A colleague of mine in Buffalo, writing on "Social Factors in Helation to the Chronic Illnesses," in the Handbook of Medical Sociology edited by H. E. Freeman, S. Levine and L. G. Heeder, comments chiefly on studies of cancer and of hypertension to this effect. Dr. Saxon Graham notes class and ethnic variations in such instances. In other words, social conditionings affecting behavior may involve cultural group or class group in hiologically pathogenic functioning. One could say, all the more, that in illnesses which are emotional and have a psychological intervening variable between culture on the one hand and personality functioning on the other, the illnesses are bound to have social and cuI· 56
tural roots in the final analysis. In the Midtown Manhattan studies, 75 per cent of the total population showed high ratings on an anxiety scale or dimension. We hasten to add that this is a global assessment which technically does not discriminate between such clinical types as anxiety neurosis and depressive states in which anxiety is prominent. However, when we did gather data on such clearly defined clinical entities as psychosomatic disorders, class and cultural variables were again prominent. In the Midtown Manhattan Study, conducted with Dr. T. A. C. Hennie at the Cornell University Medical College Department of Psychiatry, we reviewed with each community respondent a series of ten somatic disorders often assigned a psychogenic basis. These included rheumatoid arthritis, asthma, colitis, allergies, stomach ulcer, essential hypertension, and diabetes. While Hillehoe and Larimore report that over 2 per cent of American adults are affiicted with diabetes, our own findings for population strata from ages 20 to 59 was only 1 per cent, with perc~ntages of 19.4 for arthritis, 9.4 for essential hypertension, 5.3 for colitis, 4.5 for stomach ulcer, and 4.4 for asthma. The pattern of prevalence for diabetes, however, was interesting, since it increased with progressively lower social sb'ata. Social status was analyzed from the points of view of education, housing and parental occupation and income. The pattern for diabetes of finding the disorder most frequently in low-status groups, shared with essential hypertension and rheumatoid arthritis, accorded well with the belief that diabetes relates to certain ways of handling life stress. The prevalence of colitis, on the other hand, decreased with progressively lower social status, while asthma was found most prevalent at the extremes of social level. However, diabetics and ulcer patients had only medium-high scores on tension-anxiety scales relating to restlessness, nervousness, sleep disturbances and overt worries that get one "down physically," suggesting relatively passive adaptations. This they shared with ulcer patients. By contrast, asthmatics and victims of hypertension had low tensionanxiety scores suggestive of a conversion or hysteriform mechanism, whereas skin disorders, colitis, and rheumatoid arthritis corVolume V
SOCIO·CULTURAL ROOTS OF EMOTIONAL ILLNESS-OPLER
related well with high scorers on tensionanxiety scales and implied a group with more direct somatization of their problems. "'hen we commented on the Midtown Manhattan Study, and noted that diabetes increases in prevalence with progressively lower social strata, we might have added that such strata derived predominantly from immigrant and second-generation Italian, Czech, Hungarian, German and Irish communities, and that some, like the Italian for example were mainly second-generation. One has then a class component made up of ethnic components. As early as 1945, Calabresi found differences in the prevalence rates of diabetes in various ethnic groups-as a matter of fact -among Italian, Poles, Germans, and Irish, in the United States. Refining this approach in a study of several generations of much the same ethnic groups in Butler County, Pennsylvania, Graham found that diabetes (and exactly as in Midtown Manhattan, also rheumatoid arthritis and essential hypertension) showed relatively low rates in the first or immigrant generation, but sharp increases among their descendants of the second generation, this being followed by declines in rates in third and sequential generation levels. These rates of diabetes were, respectively, 12 per 1,000 for the first or immigrant generation level, 22.2 per 1,000 for the second, which is almost a doubling of rate, and 12.3 per 1,000 for generations third or over. Such rates were. of course, for a standardized age and sex composition. Graham's conclusions are like ours for the Midtown Manhattan Study. namely, that immigrant generations will themselves show better mental health status, including psychosomatic rates, than their children of the second generation. The latter arc involved, as we hypothesized for Midtown lvfanhattan, in socio-cultural strains enveloping personal stresses since parental and child values (one's parents versus ones of a peer group of age mates) stand in conflict. The concept of a continuum from well to ill in every society and culture means that "impainnent in life functioning" will vary as to types of disease and quantity of impairment in each cultural group. In 1956, in a hook titled Culture, Psychiatry and H'I/1UIIl Values, the two conceptions of "impairment in life functioning" and a cultural theory of its January-Fpbmary, 1964
epidemiology were developed. In that book, the present author surveyed mental health epidemiology through several reports from cultures around the world. Mental illnesses were found to vary both in type and in amount, or in prevalence and incidence of the disturbances, on every continent for which there were clear data. Not only that, but in Western European psychiatry, diseases had changed in type and in amount. The result was that the book postulated a relational theory of social psychiatry stating that both the forms of mental illness and the amount of disturbance vary with the cultural milieu both historically in our own tradition, and crossculturally when we compare one culture with another. The book published in 1956 was written hy the present author. In 1959, however, I published another volume called Culture and Mental Health: Cross-Cultural Studies for which I furnished only two cultural studies, but for which as editor, we gathered full contemporary studies from every continent. Thc strategy was to see whether the relational theory of 1956 held good according to the work of contemporary scholars, persons in behavioral sciences who were professional psychiatrists, epidemiologists, anthropologists. sociologists and psychologists. The relational theory, that is, the hypothesis that culture determines form of emotional illness and its quantity was again confirmed, in this instance hy 23 authors representing the above disciplines and for the most part working independently and in different continental settings. This theory, now partly confirmed, stands in sharp contrast to the ideas of Thomas Szasz in his hook, The Myth of Mental Illness. Further, the Midtown Manhattan Study first volume, puhlished in 1962, fully supports the relational theory. Both the theory and the Midtown Study state that mental illnesses, far from heing a myth or a game played by practitioners and actors, are realities, in fact widespread and probably increasing realities. Szasz holds that sympathy arousal is the ess('nce of the illness game or myth. In reality. we find that illness is the kind of malfune tioning and actual impairment in life funetioning that destroys freedom and spontaneity. In 1956, further, in our first formulation of this opposite theory to that of Doctor Szasz, we
.,7
PSYCHOSO~IA TICS
predicted that such disorders as afflict modern man are probably on the increase. We pointed out that people in preliterate cultures suffering from conversion hysterias are frequently helped by the shaman and by an abundance of community supports in {'motional crises; but that modern man, freed for the most part from conversion hysteria and simple "nuclear" forms of the schizophrenias was now open to psychosomatic disorders, deepset schizophrenias with paranoid reaction, or equally devastating affective disorders. These observations on changes in types of disorders, taken together with Midtown Manhattan epidemiology should disabuse us of the false 1I0tion that mental illness is a myth-a professionally kept secret. ~1y opposing formulation is that mental illness. now proven to he more widespread than we ever imagined hefore, is a social reality. As such, it becomes a moral problem that Dr. Szasz theoretically avoids or dismisses. The prohahle increases in psychosomatic disorders and in more profoulld forms of schizophrenias stand in contrast to such small counts of mental illnesses as Dr. M. E. Spiro divulged for the ~1icr01wsiall culture of Haluk in mv hook. Cultur(' (/1/(1 :\I ental Jlmlth. The'statistics 011 mental ht'alth in such cross-cultural surveys contrast markedly to very serious disorders in our Midtown Manhattan survey. The issue is 110 longer whether culture influences mental Iwalth epidemiology, hut rather. hou; does culture help or harm in each milieu. Freud's phrase for heing "thrust into conflict" in his work on group psychology may now he rephrased into the question: "'hat are the conditions for heing thrust into conflict. or how does personality impairment and disintegration occur? \Ve are today closer to the answers. Oviously. what Fr~'ud phrased as the
"conditions for conflict," we must, in social psychiatry, rephrase as the social conditions for conHict, for impairment, or for personality disintegration. In these formulations of social psychiatry, much has been published since 1955 in our Intemational Journal of Social Psychiatry
rounding out the picture of such conditions of existence. Our position is obviously evolutionist on a social level, as Freud's was on an individual maturational level. As evolutionists. we do not believe in an absolute relativism, hut rather, that human adaptations are to social and cultural scenes. The hope is that change in the future, informed by the findings of social psychiatry, can restore freedom and spontaneity to the prohable half of all those with illnesses today having psychological and social roots. REFERENCES
I. Freeman, H. E., Levine, S., and Reeder. L. G.
:!.
3.
4. 5.
6.
7.
H.
(Eds.): Handbook of Medical Sociology. Nf'W York: Prentice-Hall. 1963. Graham, Saxon: Ethnic hackground and illness in a Pt'nnsylvania county. Soc. Prnhlems, 4:76-82 (July) 19.56. Opler, M. K.: Culture, Psychiatr!l and Humau Value.~. Springfield, III.: Chas. C Thomas, 1956. Opler, M. K. (Ed.): Culture and Mental Health; Cross-Cultural Studies. New York: Macmillan Co., 1959. Opler, M. K.: Epidemiological studies of mental illness: methods and scope of the Midtown Study in New York. In Symposium on Preventive and Social Psychiatry. Washington, D. C.: WaltN Reed Army Institute of Research. 195R. Spiro, M. E.: Cultural heritage, personal tensilms, and mental illness in a South Sea culture. In Culture and Mental Health (edited by ~1. K. Opler). New York: Macmillan Co., 1959. Srole, L., Langner, T .. Michael, S., Opler, M. K.. and Rennie, T. A. C.: Mental Health in the .\tetropolis: The Midtown Manhattan Study. ~ew York: \fcGra\\'-HiII Co., 1962. Szasz. T. S.: The .\Iyth of Mental lll,l('s.~. ~l'\\' York: Hoeher-Harper Co., 1961.
It is natural that th(' individual sees only what he comprehends, and that he comprehends only what in his opinion ('onc('ms him. '\. H .... IITM .... SN. Quoted by Eugen Kahn in Theories of the \lind. Edited hy Jordan Scher, \I.D., The Fret' Press of Glencoe, ;'II. Y.
58
Volume \'