More than half of all hospital beds in the United States are occupied by patients with mental disorders. Nine million Americans suffer from serious mental troubles, and the number is on the increase. Estimates of the direct and indirect cost mental illness in this country range from $3 billion to as high as $12 billion a year. Meanwhile, there is a growing shortage of trained psychiatrists—there is not more than one for every 16,500 Americans. Such, in brief, was the disturbing picture which prompted Congress, in 1955, to pass an act authorizing an elaborate study of the nation's mental health.
The most arresting product, to date, of this unprecedented investigation is a 444-page document entitled Americans View Their Mental Health (Basic Books), which presents the findings of a nationwide interview survey conducted by the University of Michigan Survey Research Center. Three social scientists on the staff of the Research Center are the authors of the published report, Doctors Gerald Gurin, Joseph Veroff, and Sheila Feld.
As its title indicates, Americans View Their Mental Health is concerned with self-diagnosis, with people's own estimates of their well-being and their troubles. Such estimates are apt to be colored by defenses and failures of insight, but the authors are right in emphasizing their relevance to the study of mental health, since it is subjective evaluations which decide what the ordinary person does about his emotional difficulties. The sample selected—2460 Americans over twenty-one, living in private dwellings—is intended to be "an accurately proportioned miniature of the 'normal,' stable adult population" (my italics). It excludes, among others, all inmates of prisons and mental hospitals, and therefore does not represent the people who are most violently disturbed. Thus, the survey can be summed up as an attempt to discover how well or how badly adjusted normal Americans consider themselves, to be, and what they do about their difficulties.
Before plunging into the findings of this remarkable document, it might be as well to register some general reservations about the school of sociology of which it is a product. Leading representatives of this school have defined their function in terms that conjure up a new imperialism, whose version of the white man's burden is the application of "scientific procedures" to areas of human affairs which, as Dr. Paul F. Lazarsfeld has put it, "have remained undeveloped in this respect." The troops and colonizers of the new imperialism are interviewers and "study groups of research technicians," its armament is the almighty computer, and its monuments are volumes of statistics. Its spokesmen report that the natives are friendly: only 8 per cent are unwilling to be interviewed.
One of the few areas which exponents of "empirical scientific" sociology consider properly developed is the study of public opinion. A few years ago, Bernard Berelson of the University of Chicago announced that this field had, been completely rescued from the hands of scholarship and was now "part of science." It has become, he boasted, in the repellent jargon of the sociologizers, "technical and quantitative, a-theoretical, segmentalized and particularized, specialized and institutionalized, 'modernized' and 'group-ized.'" Any area of human behavior, Dr. Lazarsfeld has blandly asserted, could in the same way be made the object of a science of its own: "It would not be more difficult and not even more expensive to collect happiness ratings than to collect data on income, savings, and prices."
A good many laymen, and sociologists, for that matter, believe that missionaries of the statistical approach have arrogantly overstated the scientific character and possibilities of their work. The claim made by Dr. Kinsey and others that their findings are "an accumulation of scientific fact" is at best an exaggeration; the data collectors themselves concede that imponderables—the way a question is worded, the skill of an interviewer—influence their results. Plainly, the application of the quantitative method to the study of human beings has serious limitations, since feelings, beliefs, and states of mind are still beyond the reach of precise measurement. You cannot take the temperature of happiness or calculate its mass.
Empirical sociology prides itself on being atheoretical, but actually it often deals in theories, preferences, and assumptions under the counter. (Dr. Kinsey, after rejecting concepts of sexual normality as a barrier to scientific research, proceeded to write as though the sexual behavior of animals constituted a norm for human beings.) Perhaps the most annoying failing of the sociologizers is a form of pedantry which consists in proceeding as though nothing were trivial or obvious. A considerable part of their effort is devoted to establishing, with sometimes dubious statistics, what everybody knows to be true.
By and large, these remarks apply to the mental health survey, but with important qualifications. The authors have the grace not to keep flaunting the flag of science. And although they sometimes make much of the obvious or the predictable—notably their confirmation of another survey's unremarkable discovery that the rich use psychiatry more than the poor—a sizable number of their findings are news.
The mental health survey was confronted at the outset with a formidable problem—the lack of agreement among the various schools of psychiatry and psychology as to the concepts which best define mental health. The authors decided not to commit themselves to any particular doctrine, but attempted instead to straddle two widely accepted approaches: the approach which puts the emphasis on adjustment, and that which stresses "investment in life" and self-realization. Two sets of criteria—happiness or satisfaction (which are taken as signs of adjustment), and worries, problems, feelings of inadequacy (which are seen as tokens of involvement as well as of distress)—were applied to four areas of people's lives: general well-being, marriage; parenthood, and work.
This two-directional approach reveals a clear-cut contrast between people's evaluation of their happiness and their estimate of their worries, problems, and feelings of inadequacy. More than one in four of those who described themselves as "very happy" or "pretty happy" said they did a great deal of worrying; one in three of the "not too happy" worried little or not at all. It was found, too, that worry is apt to be linked to optimism unhappy people who do not worry do not expect to be any happier in the future; happy people who worry a lot expect to be happier. All this points to the conclusion that, in our culture, happiness, so far from being identified with peace of mind, is generally associated with a strong commitment to life which brings with it worries, problems, arid feelings of inadequacy.
Three themes run through the survey's findings Superior education is consistently associated with more happiness—43 per cent of the college educated rated themselves "very happy," as against 23 per cent in the grade school group—but also with more worries, problems, and except in the job area) feelings of inadequacy. Almost the same pattern is found among the young, at every educational level, the one difference being that they express less satisfaction with their work than older people. Third, women, though they do not differ significantly from men in their evaluation of their happiness, seem to experience considerably more stress: they are more worried, more aware of problems in their marriage, more likely to have felt a nervous breakdown impending.
These findings, the survey's sponsors observe, show that any evaluation of mental health depends decisively on the particular concept used. If freedom from worry and from feelings of inadequacy is the operative criterion, the older and less educated emerge as healthier; if mental health is identified with involvement and self-realization, the younger and the more educated make a better showing.
Of the total sample, 35 per cent described themselves as "very happy," 54 per cent as "pretty happy," and only 11 per cent as "not too happy." Here is a partial tabulation of the sources of their happiness (first two reasons mentioned): economic and material considerations, 29 per cent; children, 29 per cent; marriage, 17 per cent; personal relationships, 16 per cent; job, 14 per cent. Material difficulties were the leading source of unhappiness; they were mentioned by 27 per cent. The great majority attributed their unhappiness to sources 0ntide the self; only 13 per cent blamed something in themselves.
The survey appears to contradict the widely accepted view that the Cold War and the hydrogen bomb are major factors in the prevalence of tension and insecurity. In reply to the question, What things worry you most?, only 4 per cent mentioned world problems and the fear of nuclear war. This figure, however, was obtained in 1957, when relations with Russia seemed to be improving. Today the percentage of respondents worried about the world situation would no doubt be appreciably higher.
More than two thirds of the sample described their marriage as "very happy" or "above average," less than 3 per cent as "not too happy," and the rest as "just above average." This idyllic picture is contradicted by our high divorce rate, and, obliquely, by the respondents themselves: nearly half of those sufficiently troubled to seek professional help, or to feel they "could have used help," spoke of marriage as the problem area. Women are slightly more conservative than men in evaluating the success of their marriages, and they are distinctly more inclined to blame problems in marriage on their partners. This may mean that they have a greater emotional investment in marriage, which makes self-blame more threatening, or else that they feel the man has the more active role and is therefore more responsible when things go wrong.
Single people tend to be distinctly less happy than married ones, and bachelors, contrary to a richly embroidered legend, seem to be worse off as a group than spinsters: "Generally, single women apparently experience less discomfort than do single men; they report greater happiness, are more active in working through their problems... and appear in most ways stronger in meeting the challenges of their positions than men." This surprising finding is reinforced by the fact that the single women in the sample turned out to be rather older than the men, and might therefore be expected to report less happiness and more passivity.
The section on parenthood reflects, perhaps more clearly than any other area of the survey, the changes in the cultural climate produced by twentieth-century psychology. Doctrines of progressive education, the theories of Freud, the teachings of Doctors Spock and Gesell and of other authorities on the rearing of children have in their various ways placed heavy new responsibilities on parents and have tended to make them acutely self-conscious about their relations with their children. Even in the most favorably situated groups of respondents, those who reported no problems in raising their children, 30 per cent confess to feelings of inadequacy about the parent-child relationship, and 22 per cent blame themselves for lack of tolerance of the child's behavior.
Parents who suffered from frequent feelings of inadequacy mentioned discipline as a problem as often as they did "physical care and material provision." Although material provision has traditionally been the father's major responsibility, men spoke of relationship concerns as frequently as women; the women tend to feel guilty about loss of temper, the men about emotional neglect—not spending enough time with their children.
The questionnaire asked people to describe the changes that a child brings to a person's life, and on the basis of their answers their "satisfaction as a parent" was graded positive, neutral, or negative. Those graded positive showed a greater tendency to subscribe to the traditional view of parenthood; the negative group displayed most strongly the new orientation. The strain of trying to follow the new concepts presumably weighs more heavily on women than on men. This may explain an otherwise astonishing finding—fewer women express general satisfaction with parenthood than men (43 per cent versus 50), and more women take a dim view of parenthood than men (22 per cent versus 10).
One of the survey's major discoveries conflicts with the familiar thesis that increasing specialization and automation in industry have so alienated the worker from his job, have made it so mechanical and uninteresting that they have condemned him to severe frustration. The survey distinguishes between ego, or personal, satisfactions and extrinsic satisfactions—pay, security, working conditions—and, predictably, it finds that skilled, semiskilled, and unskilled workers score lower on ego satisfactions than those in the higher status occupations. What is significant is that they also score lower on ego dissatisfactions and report fewer work problems; they actually experience less frustration than the professional and managerial classes.
A plausible explanation is that men in the lower job categories expect little in the way of personal fulfillment from their work; their satisfaction depends, to a much greater degree than in the higher status groups, on the material benefits.
The group in which frustration is acute is clerical workers; 57 per cent of them—10 per cent more than in any other occupational category—said they would sooner be doing some other kind of work. Sales people, too, give a rather dim account of themselves in the job area: they are no more satisfied than unskilled workers, and they suffer from work problems nearly twice as frequently. Farmers are remarkably contented. They come slightly below the professional and managerial classes in ego satisfaction, and they lead all other groups by a wide margin in respect to not wanting a different occupation.
The criteria used to measure adjustment were supplemented by a check list of twenty symptoms, and here the tendency of empirical sociology to deal in theory under the counter reveals itself rather amusingly. One obvious way to draw up such a list would be to consult a group of leading psychiatrists, but the planners of the survey preferred to consult another survey, presumably in order to remain uncontaminated by theory. They turned to two community studies and took from them a list of symptoms which "differentiate respondents diagnosed as having psychological difficulty from respondents diagnosed as not haying such difficulty." Now, more than half of these symptoms (to which four were added) are physical—headaches, loss of appetite, loss of weight, upset stomach, trembling hands, sweating hands, aches and pains, and so on. Absent from the check list are several symptoms which most laymen as well as psychiatrists associate with emotional disturbance—fits of depression, recurring fears, acute feelings of guilt or inferiority, and the feeling that "life isn't worth living."
Thus, the survey has plumped for the view that the physical symptoms mentioned above are the most reliable indicators of trouble in the psyche, thereby committing itself to a theory which, though it has respectable backing, is certainly not accepted universally.
The major point that emerges from responses to the symptom check list is that bodily symptoms are more prevalent in the working rking class, psychological symptoms in the middle class. The survey's assumption that the bodily symptoms in question are indicators of psychological distress leads to the conclusion that the working class tends to somatize its emotional troubles, whereas the middle class experiences them more directly. In other words, clammy hands and upset stomach are apt to be the poor man's substitute for angst.
The second part of the survey investigates how Americans cope with their problems of adjustment. Fourteen per cent of the sample—a figure which purports to represent fifteen million normal adult Americans—reported that at some time in their lives they had used "professional help," a loosely defined category which includes clergymen, doctors, and lawyers as well as psychiatrists, psychologists, marriage counselors and clinics, and social service agencies that handle psychological problems. Of those who went for help, 42 per cent mentioned a marriage problem; 12 per cent, difficulties with a child; 9 per cent, problems with their relatives. Further analysis of these responses discloses that only 23 per cent acknowledged a "defect in the self." Twelve per cent explicitly described the problem for which help was sought as "nonpsychological."
The source of help most widely used was the clergyman; 42 per cent turned to him. Thirty-one per cent consulted practitioners, institutions, or agencies specializing in psychological problems; 29 per cent went to doctors; 6 per cent to lawyers; and 14 per cent to "other sources" (Alcoholics Anonymous, nurses, teachers)
Nine per cent of the sample said that at some point in their lives they "could have used" professional help. What prevented them from seeking it? One out of four said that he managed to work out the problem on his own; one out of five did not know where to turn; 14 per cent were inhibited by shame. Only 4 per cent mentioned expense as a deterrent—a surprisingly small number. The authors take this figure to mean that people in the lower income brackets are less attuned to the most expensive form of help, psychiatry, and so do not even get so far as considering it for themselves.
One of the major concerns in the second part of the survey was to determine to what extent Americans have accepted the psychiatric view that "mental health problems are illnesses rather than defects of character, and should be referred to specialized professional resources for treatment." The authors rightly emphasize that many people who accept modern psychiatry intellectually are far from ready, emotionally, to apply it to themselves. The survey therefore takes willingness to seek professional help, or to admit the need for it, as the test of whether a person has seen his problem "in mental health terms." Unfortunately, the loose definition of professional help used in the survey makes this test meaningless. What of the respondents who took problems defined as "nonpsychological" to nonpsychiatric doctors? To say that they are thinking in mental health terms is to play with the meaning of words as capriciously as Humpty Dumpty. And surely it is insulting to religion, as well as nonsensical from the standpoint of psychiatry, to suggest that all those who turned to 'clergymen were demonstrating a psychiatric orientation. Indeed, it would be reasonable to suppose that many chose clergymen precisely because they were skeptical of, or hostile to, psychiatry.
The only halfway reliable test of whether a person views his distress in mental health terms is his willingness to consult a mental health specialist, and that means some kind of psychiatrist or psychologist. From this standpoint, the survey's findings indicate that, of the people sufficiently seriously disturbed to seek help or to admit the need for it, slightly more than 30 per cent appear to have accepted the psychiatric view of emotional distress.
To what extent this view prevails among those who did not feel the need for help cannot be gauged with any precision. It is, as might be expected, much more noticeable in the responses of the younger generation and of the more highly educated. But, looking at the sample as a whole, the authors observe: "People tend to externalize their problems, to locate them in 'concrete' material things or a job, to see them as reactions to external events, not as problems in personal or interpersonal malfunctioning."
What picture do "normal" Americans give of themselves in the survey, and what conclusions can be drawn from it? Nine out of ten describe themselves as happy. Yet they report a high incidence of mental distress (and when the sampling was done, the world situation was less oppressive than it is today). One in four has had problems which took him to professional help or made him feel he needed it; one in five has felt a nervous breakdown impending. A contradiction is apparent, and one might deduce from it that our culture makes people strongly disinclined to acknowledge even qualified unhappiness. Even so, when one views the entire balance sheet presented by the survey, Americans do not appear to be quite as anguished, frustrated, and disoriented as one might gather from some of our leading social critics.
In most countries, material considerations play a considerable part in people's estimate of their well-being and of their troubles, and one cannot conclude from the survey that Americans are more or less materialistic than they are alleged to be. Many continue to find religion their surest support against distress; they turn to the clergyman for help or fight unhappiness with prayer. It has often been said that Americans give far less of themselves to family life than Europeans, but the survey observes that "well over half the population finds its greatest happiness in the home."
The stereotypes which imply that place of residence is strongly related to adjustment—the driven, joyless city dweller; the easygoing smalltown man, friendly and relaxed; the suburbanite made frantic by status seeking—get no support from the survey. The authors find that, in terms of the criteria they are applying, "a young educated male farmer is more like a young, educated, male New Yorker than either of these people is like his own father."
Although the theories of psychoanalysis and of modern psychology have been intensively popularized, the majority of Americans are still not inclined to view their day-to-day troubles in psychological terms. A good many of those who do feel the need for psychiatric help do not know how to go about getting it, and a number of them are deterred from seeking it by an outdated sense of shame. On the other hand, the impact of what might be called the Freudian Revolution is clearly apparent among the younger and the more highly educated, and it points forward to a problem. As the nation's educational level rises, and as the growing acceptance of psychiatry evidenced by the young becomes more general, the demand for psychiatric help, unless present training programs are substantially enlarged, is likely to become vastly greater than the supply.
Like the Kinsey reports, the mental health survey is a document in which there breathes the spirit of American liberalism. It was obvious that Dr. Kinsey, despite his pose of scientific detachment, dearly wanted us all to have a good sex life; and the authors of the present survey dearly want us to have a good psychological life. For all their sociological pedantry, they are holding up to us a new character ideal—psychological man. As Philip Rieff has observed, three character ideals have successively dominated Western civilization: the political man of classical antiquity; then religious man; and from the Enlightenment to the present, economic man. Now it seems to be the turn of psychological man, who lives by insight, counting his satisfactions and dissatisfactions, studying his worries, watching over his mental health. Since it was instigated by our Congress, the mental health survey can be called his first official monument.