SOCIOCULTURAL FACTORS IN MENTAL HEALTH AND ILLNESS

SOCIOCULTURAL FACTORS IN MENTAL HEALTH AND ILLNESS*

MARC FRIED, PH.D.,t AND ERICH LINDEMAIW, PH.D., M.D.$

Center for Community Studies, Massachusetts General Hospital, Boston

NE of the most pressing problems in the study of mental illness and 0 mental health is the formulation of a general definition of a case (6). Whether the focus of study be epidemiological, sociocultural, or psychodynamic, it is essential to have a consistent basis for distinguishing those individuals whom we would classify as mentally ill from those whom we can classify as mentally healthy. Any definition we employ plays a major role in determining the research design, the techniques employed, and the limits within which any results may be obtained; thus, whether the defining criteria be explicit or implicit, they influence the entire character of any research in this area.

For the past year this problem has arisen in the course of our study of a sample of persons from an urban slum area which is in the process of being demolished. Our random sample of 475 households represents a population of 2700 families living in a SO-acre tract. This large tract of land is giving way to an upper-middle-class garden apartment project as part of the city’s urban renewal program. In the midst of this situation, we are investigating the results of relocation, the problems of adaptation to a new geographical environment, and the effect on mental health of variations in social relationships, institutional patterns, ethnic status, and psychological reactions. However, the complexities of theory, methodology, and technique in studying mental health and mental illness outside the clinical psychiatric setting have forced themselves upon us from the outset. Our attention in this pres- entation is directed only to the first order of problems: an orientation to the phenomena of mental health and illness and, particularly, the relevance of sociocultural factors in understanding these phenomena.

We have come to appreciate the fact that, along with some of our most profound insights, some of our most serious biases about mental health and mental illness have arisen through the dominant role of clinical psychopathology in contemporary thought about these problems. We tend to gen- eralize the results, formulations, and models derived from clinical psychopathology to situations and populations other than the original clinical

* This is a revised version of a paper presented at the 1959 Annual Meeting. t Research Coordinator, Center for Community Studies; Associate Psychologist, Massachusetts

1 Medical Director, Center for Community Studies; Chief of Psychiatric Service, Massachusetts Gen- General Hospital; Research Associate, Harvard Medical School.

eral Hospital: Professor of Psychiatry, Harvard Medical School.

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88 SOCIOCULTURAL FACTORS IN MENTAL HEALTH AND ILLNESS

situations and to samples of people who have no common experience of seeking or acquiring psychiatric help. At the same time, we do not take full account of the extent to which we see, in the clinic, people who are “selected” on grounds other than psychopathology, or the effect of the clinical situation on the observable phenomena. Three areas stand out in which this bias is of major significance. First, concern with psychopathology has obscured the importance of social criteria in distinguishing the mentally ill from other members of the community. Second, the fact that psychiatric patients have been a primary source of data has biased our perspective by identifying illness and health with patient and nonpatient status. And third, since the psychiatric clinic has sponsored most of the dynamic work on these problems, we have tended to neglect cases which come to attention through nonpsychiatric sources: the people seen by social, welfare, and legal agencies. In addition, as Jahoda (7) and others have pointed out, since we use pathology as the starting point in our consideration of the entire mental health-mental illness problem, mental health is always defined as a residual category: the absence of any specified mental illness. Since each of these issues has a rather specific effect on conceptualization and empirical work in the field, each of these points warrants some further evaluation.

SOCIOCULTURAL CRITERIA FOR MENTAL HEALTH A N D ILLNESS The psychiatrist functions within a mandate from society to make

decisions for the community when an individual is regarded as “not respon- sible for his own behavior” (11). It is not surprising that, in this situation, psychiatric decisions are largely based on social criteria. When a decision must be made about whether or not a patient should be hospitalized, the degree or type of psychopathology is used primarily as a clue for making predictions relevant to social behavior. Criteria which are purely psychopathological cannot possibly serve as a basis for decisions in such extreme cases. Most psychiatrists would not hospitalize a patient simply because he is delusional, hallucinatory, circumstantial, depressed, manic or because he shows any other of the range of symptoms usually found in patients who are hospitalized. These may be necessary but they are certainly not sufficient conditions for hospitalization. The primary consideration, of course, is the extent to which a person is presently or potentially a danger to himself and to others. In addition to this, however, the experienced administrator has to make his decision about whether or not a patient should be hospitalized on the basis of a number of other social factors: the kind of family and community from which the individual comes, the availability of persons close to the individual, and the availability of other community resources, among many considerations. When the psychiatrist’s role is defined as therapeutic rather than as exclusively custodial such decisions involve other aspects of

FRIED AND LINDEMANN a9

the social life of the potential patient as well as the social life of the rest of the community. But his concern remains in the realm of social factors such as the adjustment, role performance, and future potentiality of the individual in relation to the social group in which he is or is likely to become involved.

In brief, the definition of a situation as one which calls for psychiatric help in extreme instances is a function both of the behavior of the individual and of the normative structure of the community in which he functions. This is often obscured by the extent to which we have incorporated the normative structure of our community into our own thought. As a general principle, when the symptoms and signs which indicate psychopathology are behavioral, they are applicable only within quite similar sociocultural systems. This is a more general formulation of familiar clinical knowledge. Ordinarily in evaluating specific behavioral reactions, such as anger or depression, the conditions in which the behavior arises form a critical element in our clinical judgment. Thus, it is neither a quantitative nor qualita- tive aspect of the anger or depression which defines its significance so much as what we call its “appropriateness,” its adequacy or excess in relation to the stimulus, and its functional significance for other psychic patterns. However, what we often refer to as the conditions, the situation, or “the external reality” may or may not be idiosyncratic social events; it may represent pervasive and regularized features of the human environment, in which case we can treat it more meaningfully as an integral feature of the sociocultural system. In this sense, behavioral phenomena can be considered pathological or nonpathological only in relation to the context in which they emerge; and regularized sociocultural patterns form the most crucial and systematic features of such environmental contexts.

I t is possible to define mental illness, at least in its extreme forms, taking more adequate account of the interrelationships between individual psychodynamic factors and sociocultural patterns. If we consider either the various criteria which are generally employed in concrete evaluations of a specific case or the stages in the development of the crisis surrounding hospitalization, we find that four conditions always obtain: 1) impulses break through the regulatory mechanisms of the ego-superego system ; 2) the behavior cannot be controlled by the normal, institutionalized mechanisms of the sociocultural system (via family, peers, work colleagues, etc.) and precipitates a crisis; 3) all efforts to support or strengthen the regulatory functions of either the ego-superego system or of the sociocultural system fail and the behavior appears as a “clear and present danger” to the normal institutional structure of the community; and 4) a t this point, when behavior is no longer under individual control and threatens the normal institutional controls of the community, reinforcement by extranormal institutional re-


sources is desired or required. The individual is then “extruded” from the communi ty.1

This formulation refers only to extreme cases of mental illness which involve the consideration of institutionalization. I ts advantage lies in the fact that it represents more generally than a definition in terms of psychopathology the conditions which lead to the empirical definition of a case. I t also points to thec‘necessity of understanding the extreme forms of mental illness in terms of several levels of analysis: 1) the psychodynamic regularities which lead to failures of control by the ego-superego system, such that impulses break through; 2) the sociodynamic regularities which facili- tate such break-throughs and which, in turn, are weak points in the regulatory mechanisms of the sociocultural system; and 3) the variability from one sociocultural system (or subsystem) to another in the concrete conditions which lead to defining a situation as a “crisis” or as a “clear and present danger.”

When we turn to the milder forms of mental illness, this definition is of little help. While an “objective” definition is meaningful for extreme cases, milder forms of mental illness require greater emphasis upon subjective factors in discriminating between illness and health. The objectively observable crisis is the starting point for defining the extreme case of mental illness, even though the concrete conditions for the development of a crisis may vary from one community to another. But milder instances of mental illness are often not even observed by the members of the social milieu and the personal difficulties of an individual may serve important social functions which impede any group awareness of individual trouble.

If we were to translate these conditions for defining extreme cases of mental illness into an operational definition, i t is clear that the operations involved would be more complex than a mere designation of symptomatology or psychopathology. It would require us to explicate the social definition of a crisis, the “normal” community mechanisms for dealing with crises, and the specific conditions for defining a set of behaviors as a “clear and present danger” to the sociocultural system. To the extent that milder forms of mental illness are largely subjectively defined, the difficulty of formulating a general definition increases. The one issue which remains clear is that, unless we are willing to settle for a wholly empirical approach to each case as a completely idiosyncratic instance of malfunctioning, we must take account of the impact of the sociocultural system in defining the demands and opportunities for role performance (and, consequently, for socially

In effect, by “extruding” the individual, we are assigning him to a special role which, from a purely rational viewpoint, is nonfunctional. Other societies may not provide such “extranormal” institutional resources but must make available equivalent nonfunctional roles (apart from functional roles which may serve to modify or even to utilize potentially disruptive behaviors in a socially meaningful way).

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meaningful impulse gratification), the flexibility of both individual and institutional structure in allowing a range of types of adaptation, and the social mechanisms (of which psychotherapy is one form) for dealing with maladaption. Glover, after reviewing the potentialities of several alternative psychoanalytic approaches to an evaluation of ego strength, concludes that social adaptation is neglected by all of these approaches and remains the single most relevant criterion (2). Likewise, Hartmann emphasizes the necessity for evaluating mental health only in relation to specific environmental situations (3). And, taking more systematic account of sociocultural considerations, Parsons points out that “the primary criteria for mental illness must be defined with reference to the social role-performance of the individual” (1 2).

Our own provisional observations on a working-class community emphasize again the importance of sociocultural factors in defining the criteria for mental health and illness. If we start with the assumption that a certain type of intimate person-to-person relationship is a sine qua non of good mental health, we would immediately exclude from the “healthy” category a large number of the people whom we have been studying who show, characteristically, a different type of relationship to other people. There seems to be less emphasis on the person-to-person intimacy we expect in middle- and upper-class Americans; yet there is considerable closeness to other people. The person whom we would classify, in this population, as well adapted is more likely to be an integrated member of some kinship, ethnic, or local friendship group. A number of the group members might be considered as “friends” but the relationship would not show the same “depth” or personal intimacy as we would expect from our middle-class norm. Or, to look a t another behavioral criterion: dependence and inde- pendence do not seem to show the same patterns or the same relationships to mental health and illness among our sample which are often described in clinical data.

At the outset of our work, we were frequently told about the “dependency” of working-class people and, especially, of slum people. And we do have the impression, to date, that the people we have been studying are more dependent, as a group, than an equivalent middle-class sample would be. But the role of this dependence and its consequences for individuals and for the group seem to be different from our conventional expectations. What we note is that dependence is part of a total cultural pattern: it is the helpreceiving aspect of a “helpgiving and help-receiving” totality. Thus, the “well-adapted” working-class person-at least those whom we have seen-automatically expects to be helped by certain other people when he is in need and, likewise, he expects to help these others when they are in need. Moreover, he maintains the kinds of group ties in which this


reciprocal relationship can readily obtain. The more poorly adapted person may retain the same expectation without maintaining the kinds of relationship which give it a vital and reciprocal meaning; or he may emphasize the helpreceiving or the help-giving without its opposite component, or he may show other types of variation. There does not seem to be any difference in the degree of dependency, per se, among those who appear healthier and those who appear sicker although there may well be a difference in the pattern of behavior into which dependency fits.

If we were to use either “intimacy” or “degree of dependence” as a criterion for determining mental illness, we would discriminate among our sample in a way which would have little bearing on other behaviors which are likely to appear healthy or ill. Yet the use of such behavioral criteria which are derived either from a culturally biased sample or, in fact, from any clinically defined group or groups leads to precisely this kind of error. That is, when we use “objective” behavioral criteria we must have fairly adequate evidence that the same behaviors have the same meaning or significance regardless of whether the person is a patient or not and regardless of the sociocultural context of his life.

PATIENT STATUS AND MENTAL ILLNESS Previously we indicated our view that a systematically biased perspective

has developed concerning the relationship between mental health and illness and the patient role. The extent to which the category of mental patient (broadly conceived) overlaps with the category of mental illness, and likewise the extent to which the category of nonpatient overlaps with the category of mental health is an important problem. However, we cannot take i t for granted that mental illness is identical with patient status. From a research point of view we would learn much were we to treat mental illness and patient status quite independently of one another and to investi- gate the extent to which mental illness is related to the seeking of professional aid, and mental health to the failure to seek professional aid. Of course, a major empirical difficulty lies in the absence of any commonly accepted definition of mental illness or mental health which is completely independent of patient status.

In the clinical situation, the identity of patient status with mental illness is facilitated because it is generally possible to find areas of conflict and unresolved issues in any individual personality. Implicitly, when a person seeks psychotherapeutic help, we assume that he is dissatisfied and this legitimates our focus upon those conflicted personality areas which lead to dissatisfaction. However, it should also be clear that it is not simply the degree of dissatisfaction, nor the awareness and sensitivity to this dissatisfaction, nor the awareness of treatment possibilities, nor even the willingness


to do something about it which determines whether or not one becomes a patient. Important current sociocultural factors influence the tolerance for dissatisfaction, the external sources employed for help in resolving conflict, and even the extent to which seeking professional aid is regarded as a sign of being mentally ill. Certainly the threshold of dissatisfaction which leads many individuals among the student and professional group into psychoanalytic treatment is considerably lower than among the working class or even among the nonprofessional middle class. Such sociocultural influences cannot explain the intragroup variability but they do point up the inter- group differences in the conditions which lead to becoming a patient. Thus, it becomes tenuous even to classify all those who are in treatment uniformly in the group of mentally ill.

The discrepancy between patient status and mental illness is even more striking if we look a t it from the other vantage point. Certainly it has become increasingly clear from the studies which have gone outside of the clinic into the community that there are many symptoms, conflicts, dissatisfactions, and disturbances among the nonpatient population which could be classified as pathological in the current sense of this term.

It is also equally clear that a list of symptoms, conflicts, dissatisfactions, or disturbances, derived from a clinical sample, cannot arbitrarily be applied to a nonclinical sample for adequate diagnostic evaluation. Studies which use this approach emerge with devastatingly high figures regarding the prevalence of mental illness. Yet such an approach can gain meaning only if it takes account of the potentially adaptive significance of phenomena which, under different conditions, might indicate psychopathology. That is, a set of behaviors may be integral to a total pattern of social adaptation despite the fact that the identical behaviors, in a patient group, may be regarded as symptoms or other pathological manifestations. Glover (2) gives many instances of patterns which may be considered as adaptive or as maladaptive, depending on the vantage point of the observer. In effect, sociocultural patterns represent general sets of regularities in terms of which it becomes more nearly possible to evaluate behaviors or personality patterns as largely adaptive or largely maladaptive.

The effect of an exclusive focus on patient samples for more general considerations of mental health and mental illness inevitably leads to yet another type of bias. We have already indicated some ways in which a given behavior has different significance depending on the context in which it arises, and have pointed to sociocultural factors as the most general and regularized sets of determinants of these contexts. We have also pointed to the importance of sociocultural factors in defining the conditions within which a person is likely to become a patient. The evidence is also begin- ning to accrue that the total treatment situation of the patient varies with


sociocultural factors. Using only a relatively gross index of one sociocultural factor, social class, Hollingshead and Redlich (4) point up a highly significant difference in the treatment situation of psychotic patients. In spite of a relatively small relationship between class status and the number of new cases of psychosis which come to professional psychiatric attention, there is a very strong and consistently linear relationship between class status and cases in continuous treatment. That is, a t any given point in time, the lower the social class, the larger the percentage of diagnosed psychotic patients in treatment. I t follows that psychotic patients who are of lower- class status must be either harder to treat, or they do not receive the benefits of the most effective treatment methods, or the criteria for dis- charging them are more stringent than for patients of higher class status, or there is greater family or community resistance to their discharge. Regard- less of the source, however, the treatment situation for psychotic patients does seem to depend, to a fairly considerable extent, on their class status. We can well anticipate that, were we to consider other sociocultural factors as well, e.g., ethnicity, community type, or other aspects of social stratifica- tion, we would find important relationships to many issues in mental health and illness.

The third way in which a focus on psychopathology limits our view of the phenomena of mental health and illness is in the range of types of deviant behavior generally considered. In recent years there has been an increasing tendency to include, among the categories of mentally ill, some of those cases which do not ordinarily come to the attention of the psychiatrist, psychologist, and social worker. But our conceptions of mental illness do not yet take account of these cases. Most striking among this nonpatient population are legal offenders and chronic-problem families. Like the extreme cases of psychopathology, they often come to the attention of public and private agencies involuntarily. In fact, the four-stage definition of extreme mental illness can apply equally well to the criminal-delinquent group and to chronic social problem cases. Furthermore, whether an individual is

extruded” to a legal or social agency rather than to a psychiatric agency may well be due to factors other than the type of problem behavior. In any event whether the psychodynamic, social, or cultural factors involved in the three different “types” of deviant behaviors have common compo- nents or not, they present a sufficient number of similar issues to be treated as aspects of the general problem of mental health and illness. Likewise, any general theoretical formulation should be comprehensive enough to include the diverse behavioral and institutional patterns of these groups.

CONSIDERATIONS FOR A DEFINITION OF MENTAL HEALTH To the extent that we formulate questions about the relationship be-

tween mental health and illness and specific psychological, social, and cul-

1 6


tural variables, we must cope with the problem of defining both illness and health in more discriminating fashion (10). And if we wish to study large samples, we must be able to extract from our definition some feasible indices for making evaluations without extensive clinical information. From a methodological point of view, we can use a number of different definitions of mental health and illness and assess their comparative merits or we can examine a number of the different dimensions implicit in our conceptions of mental health and illness. Subsequently, we can study the relationship between these differently defined conceptions of health and illness or between the several dimensions and other potentially relevant variables.

In our study of the impact of relocation on mental health and illness, we are pursuing both procedures. Thus, our data include indices of patient status, symptomatology, social adaptation, personality, and reactions to dislocation-relocation. We are also in the process of examining some of the dimensions which seem to be at the core of our current conceptions of mental health and illness in their most generalized forms. And it is with respect to our preliminary considerations concerning one such dimension of mental health and illness that we wish to conclude our discussion. However, we should emphasize, not only the preliminary nature of these ideas, but the fact that we regard mental health-mental illness as a complex, multi- faceted variable although, in the subsequent discussion, we consider only one set of the dimensions which we believe to be pertinent.

We have decided to consider mental health and illness in terms of multidimensional variables which are the resultants of complex organism-environment processes. Such variables must take some vantage point with respect to the ego in relation both to internal and to external events. Since a much greater share of explicit attention has been devoted, at least from a dynamic viewpoint, to the ego in relation to internal events, we have initiated our study of mental health variables with a focus on the ego in relation to external regularities.

The variable we have formulated is designated Role Satisfaction. We define Role Satisfaction as the extent to which a person can accept an institutional definition of his roles with minimal conflict between personal needs and the externally provided definition of the situation. First, we should indicate that we distinguish this variable, Role Satisfaction, from the usual satisfaction-dissatisfaction dimension. We are not primarily concerned either with a generalized sense of satisfaction or with a simple satisfaction-dissatisfaction balance, based on a multitude of individual responses of satisfaction or dissatisfaction. While other aspects of satisfaction-dissatisfaction may have a bearing on mental health and illness, we believe that the crucial adaptations which we designate as mental health (and likewise the crucial maladaptations which we designate as mental illness) concern role behaviors in general and, more specifically, those roles which are central to the major


functions of the social system. As Parsons has pointed out, “Since it is a t the level of role-structure that the principal direct interpenetration of social systems and personalities come to focus, it is as an incapacity to meet the expectations of social roles, that mental illness becomes a problem in social relationships and the criteria of its presence or absence should be formulated” (12).

On the other hand, we must distinguish Role Satisfaction from the related variable, role performance. In a practical sense, evaluations of role performance are likely to be useful in designating mental health or illness primarily in extreme instances. In milder cases, a major discrepancy arises between role performance and mental health status since high performance levels can be maintained for extended periods of time despite considerable psychic cost for the individual or for members of his social networks. Thus, a model husband-father-son-colleague-etc. may show high levels of role performance in a wide variety of institutional spheres only to succumb in all of them, after a period of time, because of ulcers, psychosis, or intolerable tension. Sociocultural variation also introduces a problem in evaluating role performance which is comparable to the evaluation of symptoms and signs of psychopathology. The criteria for effective performance of a worker role not only vary from one class group to another, from one ethnic group to another, and from one geographic area to another, but even from one factory to another. The very standard which may be used is equivocal: Is a worker’s role effectiveness determined by output, by his co-worker’s judgments, by his foreman’s evaluation, or by his own self-estimate? These are not simply added difficulties for an evaluation; they are essentially insuperable problems a t any general level of formulation. Empirical criteria (and to be useful any evaluation of role performance must be empirically concrete and culturally biased) have serious limitations as soon as one shifts either the vantage point of the observer or the context in which the empirical criteria were designed.

Role Satisfaction, as we use the term, is seen as a continuous variable. Role-satisfied people, a t one extreme, represent those individuals who have been able to integrate institutionally defined role demands and available role opportunities with personality-defined needs, wishes, and strivings. Whether this is accomplished through an already available “fit,” or through adjusting motivational demands to the role pattern or restructuring the role to the personality is not crucial for defining the person as role satisfied. The middle groups in the Role Satisfaction-Role Dissatisfaction continuum include a variety of types of lack of social commitment: the ambivalent, the uncertain, the relatively uninvolved, as well as the weakly satisfied or weakly dissatisfied, At the other extreme, of course, are the role-dissatisfied people who have been unable to relate personal goals to socially defined


roles. The extent to which Role Satisfaction is a general characteristic, i.e., the likelihood that a person who is satisfied with one role will also be satisfied with other roles, is an empirical problem. From the point of view of over- all adaptation, it is more important that certain roles be experienced as satisfying than others. In the American middle class, work and marital roles, for example, have considerable primacy over other roles. It is not surprising that Freud’s succinct definition of normalcy as the ability to love and to work focuses on precisely these two roles. The specific importance of different roles (such as the family of procreation role, the role in family of orientation, the occupational role, and the peer group role) may be universal.

Role Satisfaction carries an implicit time dimension. A person may be satisfied or dissatisfied with a given role or with all of his roles a t one point in time and not a t another; or he may be chronically dissatisfied with his roles. There are a number of important empirical problems involving the frequency of such changes, the degree of such change, and the areas in which such shifts are most likely. The time element in Role Satisfaction is related to the fact that, within certain limits, several alternative roles are often available or alternative definitions of a role are possible. Thus we would assume that Role Dissatisfaction, for the healthy person, involves attempts to change his role or to redefine a role, in this way establishing or re-establishing Role Satisfaction.

To the extent that Role Dissatisfaction persists over periods of time, we would consider such dissatisfaction a significant index of mental illness. Nevertheless, there are certainly institutionally defined limits to the possibility of such change of roles and alternative definition of roles. These limits vary from one culture to another, they vary with status in the strati- fication system, and they vary from one institution to another. When such limits on role flexibility are broadly defined by the culture and apply across all institutions, they have a relatively uniform social effect. We could not, in this situation, attribute mental illness to the cultural limits on role flexibility. Only the rather unlikely demonstration that all such societies (with severe and encompassing limitations to variation in role activity) show higher rates of mental illness would indicate a causal factor in the cultural restraint on role behaviors. However, when the limits on role flexibility vary with social status, class or caste, there is likely to be some strain on the mutual relationship between role performance and need gratification which might manifest itself as different class rates for mental illness. That is, when there are different externally imposed limits to the possibility of shifts in roles or in role definitions depending on class status, or in any discriminatory fashion within a social system, we may be able to speak of specific sociocultural determinants of mental health and illness.

Our work to date suggests, along with other studies of the working class,


that there are more severe restrictions on freedom of role definition and role selection for the working class than for middle- and upper-class Americans. Whether in the sphere of occupational activity, educational choice, or familial patterns, members of the lower class less frequently have the opportunity to make an initial choice from a wide range of possibilities, to alter their choices without drastic consequences, or to reformulate the definition of the situation so that it is more need-gratifying and remains socially accept- able. Although this may not be uniformly so in all institutional areas, it seems to be predominantly the case. This impression can be related to an observation Alex Inkeles ( 5 ) has made. On the basis of preliminary work on poll results which have been obtained throughout the world, Inkeles finds that working-class people show stronger and more widespread dissatisfaction, are less optimistic on a wide range of issues, and are less confident and self-confident than the middle or upper class. We would anticipate that in this area of the rigidity or plasticity of institutional definitions of roles and the relationship between such limitations and Role Satisfaction lie some of the most important sociocultural regularities which affect mental health and mental illness. The existence of such sociocultural regularities would not vitiate the importance of psychological determinants of mental health and illness but they would establish some of the basic conditions within which specific psychological patterns are likely to produce “pathology” and the extent to which conflicts between need systems and institutional roles lead to the phenomena of mental illness.

In spite of the relevance that Role Satisfaction seems to have as one component of mental health and mental illness, and despite its potential for bringing together psychodynamic, social, and cultural influences, it cannot suffice for defining mental health and mental illness. Many of the conceptual criticisms of the adjustment concept as a criterion of mental health apply to this subjective aspect of adjustment as well. Role-satisfied people tend to provide support for the current institutional structure and role-dissatisfied people tend to introduce problems which challenge the status quo. Since we believe that social change and social conflict are as critical for social processes as are maintenance and stability, it is necessary to consider some of the limitations of Role Satisfaction as a mental health variable.

From this point of view, we would assume that role-satisfied people are also likely to show up among the mentally ill when their entire orientation is based on institutionally provided role definitions. Such exclusive dependence on institutional definitions of roles leads to inflexibility in role performance and, therefore, involves serious limitations in adjusting the relationship between social roles and need systems when strains occur. By contrast, role- dissatisfied people may be sufficiently capable of changing roles or redefining roles to develop a meaningful adaptation to the social system; and their Role


Dissatisfaction may provide an adjustive mechanism which encourages socially significant activity in the service of the Role Dissatisfaction. Such activity is likely to be a major force in social change. If the social values implicit in a conception of mental health and mental illness are considered, we must take account of the socially constructive aspects of Role Dissatisfac- tion and of the socially constricting aspects of Role Satisfaction. This limita- tion can be accounted for by the use of other component variables in a more inclusive definition of mental health and illness.

Regardless of the criterion or criteria employed, there are technical problems in assessing any aspect of mental health or illness. In the use of survey research interviews or any other assessment method which involves only relatively brief contact with a subject and/or is limited to the respondent’s own report, the difficulty lies in getting accurate data in spite of conscious and unconscious defensive reactions. We cannot assume, of course, as Allport has pointed out (l), that simply because information is readily available it is thereby irrelevant to some of the most critical issues of life. And, in fact, we believe that information about Role Satisfaction is less subject to conscious and unconscious distortion than is data about many other personal issues. First, both direct and indirect questions concerning Role Satisfaction deal with either relatively impersonal areas of social activity or can be formulated so that we are dealing with relatively remote derivatives of a potentially conflicted issue. Secondly, Role Satisfaction is so fundamental an aspect of a person’s daily social life and has such phenomenal significance that it cannot readily be rejected from awareness. Moreover, the implications of a person’s role satisfaction or dissatisfaction for his unconscious conflicts may be kept from awareness without impeding his consciousness of experienced Role Satisfaction.

In reviewing the interview records of individuals who have been classified “Role Satisfied” or “Role Dissatisfied” in our sample, the data for the large majority of the cases present a meaningfully consistent picture, suggesting the absence of serious distortion. However, a number of cases show incon- sistencies which seem due to the operation of various defenses. In particular there are several relatively small groups of people who are likely to give distorted responses concerning their Role Satisfaction. Thus, those who deny all evil, who must always maintain a fasade, are likely to be rated as role satisfied in spite of major role dissatisfactions which are revealed only in subtle ways. On the other hand, those individuals whose dependent wishes for sympathy or whose vested interests in suffering are readily called forth in interview situations are likely to appear more dissatisfied with their roles than they are in fact. Clinically we are also familiar with the frequency with which many psychotic patients indicate their complete satisfaction with all roles in spite of the evidence that the only role in which they can comfort-


ably participate is that of the extremely sick person. These groups present special problems in the use of Role Satisfaction as a variable for the practical assessment of mental health and illness in a population. However, the type of problem is familiar in the use of various psychological assessment procedures in research and it is possible to minimize the effects of such distortion on the results.

It would be premature to present any detailed exposition of findings so early in the study and we wish only to delineate some of the directions in which further work is going. In the light of our previous methodological comments, we have separated the analysis of this variable into several procedures. Ideally, we wish first to validate the variable. That is, we first ask the question: To what extent does a “score” on Role Satisfaction correspond to scores or ratings on other indices of mental health and illness? As we have emphasized, no adequate definition or index, particularly of cross-cultural applicability, is available for assessing mental health and illness. The only alternative, as a first step, is to select other items and issues which have considerable, commonly accepted relevance for assessing mental health and illness, and to view the total set of relationships as a basis for validation. Issues such as relationships to other people, affective expressiveness-control, care-taking agency use, and responses to projective items all fall into this category. In view of the special characteristics of our research design, we may also have an opportunity to assess small samples through more intensive, clinical evaluation and to compare the Role Satisfaction ratings based on the survey interview data with the results of clinical study. Such “validation” procedures, however, represent only a part of a meaningful analysis. It is also possible, through intensive internal analysis guided by hypotheses, to evaluate the social and psychological significance of Role Satisfaction in a variety of life contexts: attitudes to relocation, success and style of adaptation to a new neighborhood, family patterns, community participation, orientation to the future, among other issues. On this basis, it becomes possible to clarify the range of relationships, of varying degrees of strength, which Role Satisfaction bears to other life activities. While this does not serve to “validate” the variable as a component of mental health and illness, it does serve to show the usefulness of the dimension for future predic- tion to a range of behaviors.

SUMMARY The main theses of our discussion are that 1) in studying mental health

and illness, we have been biased by the focus on the phenomena of psychopathology and by the conditions in which we assess psychopathology, and 2) we have particularly neglected the sociocultural regularities which influence both the emergence of these psychopathological phenomena and the


conditions of observation of psychopathology. In trying to develop more effective definitions and approaches to large scale studies of mental health and illness (and to take account of the “healthy” side of these phenomena) we are developing multidimensional variables for assessing mental health and illness. These variables emphasize the relationship between psychological and sociocultural regularities. The first variable we have used is Role Satisfaction, which focuses on the “socially adaptive” aspect of mental health and illness. Further study is in progress both to clarify the significance of this variable and to formulate additional variables which, together, may provide a meaningful operational definition of mental health and illness.

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ness. New York: Wiley, 1958.

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SOCIOCULTURAL FACTORS IN MENTAL HEALTH AND ILLNESS