COLLEENL. JOHNSONAND FRANKA. JOHNSON

PSYCHOLOGICAL DISTRESS AMONG INNER-CITY AMERICAN ELDERLY: STRUCTURAL, DEVELOPMENTAL, AND SITUATIONAL CONTEXTS

ABSTRACT. This analysis explores the prevalence of psychological distress and the factors associated with its occurrence among 200 inner-city residents, 65% of whom are African Americans. Comparisons by gender and race find that women and African Americans are less likely to be distressed. Distress, however, is significantly associated with poorer health and fewer social and economic resources. A model depicting pathways to distress is used in a case study analysis of the most distressed respondents. It illustrates how the developmental vulnerabilities in childhood, limited opportunities in adulthood, and the provoking agents in their current lives interact and undermine well-being. This paper raises the proposition that a levelling process may occur in later life when these factors converge and result in distress irrespective of cultural differences.

The description and labeling of psychological states among older people varies considerably according to the researchers' academic background, interests, and their social constructions of the phenomena they study. Gerontologists generally focus on concepts such as "well-being," "life satisfaction" or "morale," while clinicians use terms such as depression, demoralization, or psychological distress. This divergent usage most likely accounts for the inconsistencies found in current research findings on the mood states of older people. While depression is generally considered the most common functional disorder found among members of this age group, current research findings do not consistently support that assumption (Newman 1989). There is some evidence from epidemiological surveys of a lower incidence of depression among older people but higher reports of depressive symptoms (Gatz and Hurwicz 1990; Link and Dohrenwald 1980). In fact, Blazer (1989) reviews findings that indicate declines in clinical depression among older people today and concludes that for unknown reasons, they may be more protected than members of earlier cohorts. Several explanations have been tendered to clarify this discrepancy. First, the fact that older people have a higher rate of self-reported symptoms might be related to the high prevalence of physical symptoms such as sleep disturbance, poor appetite, and diminished energy (Gatz and Hurwicz 1990). Researchers have consistently found that self-reported well-being is associated with perceived health (Arling 1987; Tessler and Mecnanic 1978; Romaniuk, McAuley and Arling 1983). Second, the simplicity of the measurement strategies most likely obscures symptoms which are manifested differently among older people (Newman 1989; Newman, Engel and Jensen 1991). Likewise, there are problems of reconciling the records of clinical judgements and epidemiological findings. While health care professionals tend to view the elderly as infirm, socially isolated, and Journal of Cross-Cultural Gerontology 7: 221-236, 1992. © 1992 Kluwer Academic Publishers. Printed in the Netherlands.

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depressed, wide-scale community studies find a population that is healthy and well-adapted (Newman, Engel and Jensen 1991). Newman (1989) suggests that more can be learned through phenomenological research which explores the perspectives of the older people themselves. Third, epidemiological studies have only recently turned to examine the life situation and the cultural context of the symptomatic older people. Studies have consistently found that distress or lowered well-being among older people is associated with poor physical status, economic problems and social isolation (Arling 1987; Luke, Norton and Denbigh 1981; Romaniuk, McAuley and Arling 1983). While those with poor health status and impaired functioning on their activities of daily living are the most likely to have lowered mood states, women, whites, the less educated and those living alone are also more often affected (Arling 1987). A small proportion of older people (2% to 3%) have been diagnosed as having severe depression (Blazer, Hughes and George 1987; Gudand 1976; Luke, Norton and Denbigh 1981), although higher proportions report depressive symptoms (Link and Dohrenwend 1980). Research using stress models generally uses mood states as an outcome variable (Pearlin, Menaghan, Lieberman and Mullan 1991). These findings indicate that there is a causal connection between social integration and both physiological and psychological functioning (House, Landis and Umberson 1988; Berkman and Syme 1979; Verbrugge 1979). Differential exposure to life strains according to cultural background is associated with high risk outcomes with the poor and minorities being particularly vulnerable (Brown, Bilfulco and Harris 1987). Such models, however, also need to identify more specific cultural factors which can influence how individuals differentially interpret the meanings of stressors (Johnson 1985). Blocked aspirations, attacks on self esteem, feelings of alienation and unfulfilled needs are differentially experienced and defined, particularly as these subjective states interact with the stressful social conditions of contemporary inner-city living. Similarly, the elderly characteristically have more limited resources in regard to their personal networks due to widowhood and deaths of age peers. A long tradition of prospective clinical research documents how the delayed effects of traumatic early life events and subsequent socialization pattems ultimately affect the development of clinical states of depressive and panic disorders (McKinney 1986; Faravelli et al. 1985; Thomas and Chess 1984; VaUaint 1984). In overviews, John Bowlby (1982; 1988) concludes that emerging research findings in Great Britain are revealing complex interactions between emotionally mediated bonds and mental health, both developmentally and situationally. This ethologically-oriented research suggests that a distinction must be made between current psychological functioning, elements of personality, and cultural factors which shape the meanings of adverse life events. For example, Bowlby (1988) concludes that vulnerability is closely linked to how people feel about their lives - whether life is viewed as enjoyable or as a burden to be endured. He suggests that we must think of interactions and transactions that are constantly changing between persons and their environ-

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ments as they move through subsequent developmental pathways. Mobilizing findings from large, representative samples, Brown and Harris (1978) have used a biographical approach to study the association between the early loss of a mother and clinical depression in adulthood. They find that provoking agents in the contemporary situation interact with the effects of adverse events in early childhood to make individuals particularly vulnerable to depression in adulthood. In their model, provoking agents can be a loss of a person, a role or even a conviction or ideological investment. Also included are ongoing difficulties in their current situation, such as lower class status or a conflictual marriage. These investigators maintain that the individual's past vulnerabilities increase the risk of depression, but only in the presence of current provoking agents. Given the widespread publicity concerning the social disorganization in our inner cities, one would expect that large numbers of elderly, particularly those in minority groups, face undesirable contingencies that make them prone to psychological distress. Yet there is a paradox in the literature. African Americans are less likely than whites to suffer from depressive symptoms, yet they are more likely to experience social stressors (Johnson and Barer, 1990). However, these findings are difficult to interpret, indicating the need for more research on the possible levelling effect occurring with advancing age when members of each group experience the same vulnerabilities and current stressors. For example, we have found that African Americans in this sample in comparison to whites are significantly less likely to be psychologically distressed (Johnson and Barer 1990). One explanation can be traced to the finding that African American elderly have more extensive friendship and associational memberships, a situation which may ameliorate the effects of potential stressors. THE PURPOSE This paper is an exploratory analysis of the cultural, situational and developmental contexts in which psychological distress is likely to be found in a particularly vulnerable sample of inner-city, predominantly minority elderly. Distress is defined here as a subjective mood state which is manifested by reports of sadness, anxiousness, withdrawal, and/or fearfulness. First, its purpose is to provide a profile of those who are likely to be distressed, as they vary by gender and race. Second, comparisons are made between whites and African Americans in the prevalence of psychological distress. The question is raised about whether there is a levelling effect occurring between members of these cultural groups when they share the same cohort membership, socioeconomic status, similar developmental vulnerabilities and contemporary stressors. Third, case studies will be used to illustrate the relevance of John Bowlby's model, "the pathways to depression." The following case materials examine interactions between the antecedent family events in childhood and early adulthood, the opportunity structures available to them through adult life, and the contemporary vulnerabilities posed by inner-city living. Here we intend to use the phenomenologi-

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cal approach to explore these respondents' perspectives with the purpose of generating hypotheses rather than testing them.

Methods of Investigation This report stems from a research project in which the overall purpose was to examine the formal and informal supports of socially vulnerable, inner-city elderly. We were particularly interested in looking at how the health care system did or did not satisfy latent social needs for the more isolated elderly. Respondents were selected from the patient rolls of general medical clinics at two hospitals in San Francisco which serve inner-city residents. One day each week, all English-speaking patients, 65 years and older, who were registered for an appointment were selected. A letter was sent to each of them describing the research. This was followed by a telephone call to schedule an appointment. The data were collected by focused interviews, usually conducted at the patient's home. Thus it was possible to observe the living environment first hand. The interview format combined in-depth, open-ended discussions as well as structured questions. Relevant qualitative data were coded by two researchers and showed an overall reliability of 83%. Economic Status was a self-reported variable ranging from excellent (1) to poor (4). Perceived health status was selfreported using a 4-point scale ranging from excellent (1) to poor (4). Functioning was evaluated by the Activities of Daily Living (ADL, 6 items) and the Instrumental Activities of Daily Living (IADL, 8 items). A score for psychosomatic symptoms was made on the basis of complaints about sleep disturbances, worries about health, being in pain, and low energy. The score ranged from zero for no symptoms to four for all of them. Psychological Distress was measured on a 4-point scale ranging from very happy (1) to very unhappy (4) by double coding open-ended responses to items from the Bradburn Affect Balance Scale and from open-ended questions asked during a life review. The latter included questions such as "What is the best time of your life?" and "What are the good things about your current situation?" Those identified as the most distressed were singled out for a case study analysis and were identified as "very unhappy". Information on supports from members of the informal social network was elicited by questions on the amount o f aid received from each category of relationship (spouse, child, relative or friend). The level of support from the family and friends was evaluated by examining: (1) the amount of instrumental supports such as transportation, household help, and shopping; (2) the amount of expressive supports indicating the level of positive sociability, emotional rewards, shared interests, and joint leisure activities; and (3) the frequency of social contact. The responses on supports were coded on a four-point scale ranging from "very supportive" to "nonsupportive." (3) Social contacts is a total score of those relationships seen at least weekly. Religiosity or regular church attendance is a final indicator of social integration.

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THE RESULTS

Sample Characteristics Table I reports on the characteristics of the respondents according to race and gender. The sample is 26% white, 65% African American, and 9% other minorities. In the following comparisons by race, the other minorities are omitted. In their demographic characteristics, only 17% are married with significantly more men than women and more whites than African Americans having a spouse at the time of the study. Correspondingly, the majority of the sample lives alone and almost one-half have no children in the area. In their economic status, significantly more whites report better resources, although onefourth of the entire sample describe their financial situation as "poor." This profile suggests a potential scarcity in social supports available should the need arise, a finding which is consistent with the fact that 27% receive no supports from family members. The church, however, is a significant source of social integration among African Americans. In their physical status, 57% of the sample report their health is "fair" or "poor," while 42% have some impairment on their activities of daily living. Complaints indicative of depressive symptoms are also commonly reported, with over one-half of the sample mentioning sleep disturbances, low energy and worries about their health. Over one-third describe themselves as experiencing pain. Fifty-four percent of the sample report that they are happy or mostly contented, 25% are intermittently contented and 21% report they are very unhappy. African Americans are significantly less likely to report psychological distress as are the women in the sample.

Correlates to Psychological Disress Table II reports t-tests and correlations by demographic characteristics between psychological variables and physical and social characteristics. Among the demographic variables, women had a significantly lower level of distress. In physical status, perceived health is highly associated with the psychological variables; functional level is significant but to a lesser extent. Economic and social resources are also significantly associated with evidence of psychological distress. Those who are poorer, who have fewer instrumental and expressive supports, fewer social contacts, and less satisfaction with family and friends are consistently more distressed. Moreover, those who are not active in their church are among the more distressed. The level of psychosomatic complaints is less related to social variables, except for the high complainers who receive less expressive supports and are less satisfied with their friendship relations.

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COLLEEN L. JOHNSON AND FRANKA. JOHNSON TABLE I Sample characteristics by gender and race (by percentage).

Marital status Married Not married HousehoM With others Alone Children present None One or more Economic status Excellent/good Fair Poor Perceived health Excellent/good Fair Poor Functional impairment None One or more Psychosomatic complaints Sleep Energy Worries Pain Psychological distress Happy/mostly contented Some distress Distressed Family supports No Yes Religiosity Yes Some No

Total

Gender

Race

(200)

Males (61)

Females (I 39)

Whites (52)

Blacks (129)

17% 83

26% 74

12% 88*

23% 77

14% 86*

64% 36

44% 56

32% 68

31% 69

39% 61

46% 54

48% 52

43% 57

46% 54

46% 54

17% 60 26

17% 58 25

17% 60 23

29% 57 14

14% 56 30*

43 % 36 21

39% 36 25

44% 36 20

52% 29 19

37% 39 24

58% 42

59% 41

58% 42

60% 40

56% 44

54% 51 53 39

44% 44 54 31

58% 49 52 42

62% 56 50 41

51% 48 53 39

54% 25 21

43% 25 34

57% 25 17"

50% 13 37

56% 29 14"*

27% 73

31% 69

22% 78

38 % 62

22% 78

29% 23 48

7% 21 72

39% 23 38***

8% 37 56

40% 13 47**

* p < 0.05; ** p < 0.01; *** p < 0.1301. PATHWAYS TO LATE LIFE DISTRESS To identify the cultural, developmental and situational factors related to psychological distress, interviews with those who were identified as the most distressed (21%) were singled out for analysis. These unhappiest respondents

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TABLE II T-tests and Pearson Correlations between social and physical characteristics and psychological characteristics. (n = 200)

T-test: Gender: Race: Household: Marital status:

Male Women White Afr. Amer. Alone With others Not married Married

Psychological Distress

Psychosomatic Complaints

£ 2.98 2.51 2.83 2.54 2.67 2.63 2.64 2.73

~ 8.26 8.63 8.67 8.45 8.63 8.34 8.53 8.46

Correlations: Perceived health ADL/IADL Economic resources Instrumental aid Expressive aid Social contacts Satisfaction with: Family Friends Religiosity

SD 1.10 2.04** 1.29 0.97 1.04 1.14 1.09 1.08

SD 2.31 2.57 2.63 2.46 2.57 2.39 2.51 2.48

0.4325*** 0.1694" 0.1779" -0.2405** -0.3489** -0.1993

0.6702*** 0.5294*** 0.0962 0.0522 -0.1442" -0.0302

0.2922*** 0.5116*** 0.2679***

0.0814 0.2248** 0.0624

* p < 0.05; ** p < 0.01; *** p < 0.001. generally had experienced stressful life events in the past in addition to dealing with adversity in their current circumstances. These observations led us to explore more about the developmental process which in combination with problematic contemporary conditions may undermine their sense of well-being. This analysis uses the model depicted in Figure 1 which demonstrates a likely chain of events leading to psychological distress. It has been adapted from Bowlby's "Female Pathways to Depression" (1988), and the work by Brown and Harris (Brown and Harris 1978; Brown, Bifulco and Harris 1987; Harris, Brown and Bifulco 1987). Three categories were useful in mapping the trajectories of their lives. First, the developmental antecedents examined include those family events occurring in the past which may have increased the individual's subsequent vulnerability to experiencing distress. Second, social structural deprivation includes those events and situations which resulted in limited opportunities over the life course which resulted in the debilitating effects of poverty or marginal socio-economic subsistence. Third, current provoking agents include such factors as poor health, limited physical functioning, a threatening neighborhood environment, inadequate housing and the absence of protective social ties. As the following case studies indicate, it was rare that only one category of

Inadequate socialization Education Terminated early Foreign birth Rural poor

Fig. 1.

Psychological Distress

\

Old Age Health Status Environmental Pressures Multiple chronic diseases Fear of crime / drugs Functional impairment Economic problems Relocation Fear of landlord

Current provoking agents

> Economic Deprivation Early disengagenment from work Disability and welfare dependency

) Middle / Late Adulthood Unsupportive / distracted children Deaths of family members Withdrawal from friends Lack of social supports

Lowered Aspirations Immigration Migration to cities Unskilled labor Erratic work history "Fast lane" life style Substance abuse

Early Adulthood Marital instability Early parenthood Early introversion

Structural deprivation

Childhood ) Death of mother Parental marital instability Childhood chronic disease Parental neglect Foster homes / orphanages Problems with object relations

Developmental antecedents

Model depicting sources of distress among inner-city American elderly.

z 0 z

o z

,e Z

~3 O

tO to oo

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events was independently associated with distress. Instead, there usually was a combination of factors occurring together to undermine the morale of the most distressed individuals. This conclusion is in agreement with Brown and Harris (1978), who suggest that provoking agents act in conjunction with developmental vulnerabilities to increase the risk of depression.

Developmental Vulnerabilities Two common developmental problems were reported. First in a few cases, distressed respondents had debilitating childhood illnesses which interfered with their development. Second, family breakdown in the early lives of these distressed respondents was common, usually with marital instability of parents, the early death of a mother, the absence of a father, or parental alcoholism. Some respondents recounted inadequate nurturing by relatives, foster parents or in a few cases, the staff of orphanages. Others described their role as surrogate parents for younger brothers and sisters while still in their early adolescence. Not surprisingly, most of these individuals had an abbreviated or discontinuous education. Teenage pregnancies, fragile early marriages or informal unions were reported by most of the women, which often initiated a life-long pattern of marital instability and the subsequent strains associated with heading a oneparent family.

Social Structural Deprivation At each stage in their developmental cycle, socio-economic factors and life events interacted, often resulting in limited opportunities and permanent lowerclass status. Most African Americans in this economically marginal sample had migrated as young adults to San Francisco from the rural South during World War II when well-paying jobs were plentiful. With the return of the ex-servicemen and redistribution of defense workers, their brief prosperity ended. At some point, their youthful aspirations disappeared. As one woman said, "I could see that I was never going to get anywhere." Among this sample, adaptation to low paying, unskilled jobs became the norm (usually because of their limited educational background). Along with their truncated aspirations, several developmental patterns occurred. One option for men consisted of a hedonistic lifestyle, travelling in the "fast lane" or "a life on the streets." Intermittent employment, heavy drinking, gambling and casual liaisons with women characterized their lives. Many women retreated from marriage following negative experiences and concentrated their energies on raising children and church activities. The more socially isolated men and women described the period of their early adulthood as a time when they established a pattern of introversion, resignation and avoidance. As one man recounted, " I ' v e always been a loner." Some of the abbreviated social networks, witnessed at the time of interview had begun many years previously.

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The social background of the white respondents who were living in the inner city paralleled those of the African Americans. Several were orphaned and had been raised in institutions. Others came from poor rural areas, while a small number had emigrated from other countries. These respondents were more likely to have come from broken families. They also had little education, a history of erratic employment, and an adult lifetime of economic insecurity. Still others had a history of alcoholism or a combination of medical and psychiatric conditions which had left them seriously infirm by old age.

ContemporaryProvokingAgents The immediate environment of the persons interviewed in this sub-sample provided stressful provoking factors that operated to undermine well-being. Housing was often limited to single residence occupancy hotels or small, dark apartments. Reflecting the age and lowered activity level of their tenants, living quarters were frequently unclean. In several instances, mice or roaches were observed during the interview. Noisy teenage groups commonly congregated in the courtyards of public housing facilities in a manner that was threatening to the older tenants. There were complaints about the visible use of drugs and the frequency of crimes in their neighborhood. Realistic fears of being assaulted or robbed had isolating effects. Individuals were cautious about venturing out from their apartments, especially at night. Economically, most of these subjects lived on minimum social security or SSI income which, although reliable in arriving monthly, provided only marginal subsistence. With gentrification encroaching on their neighborhoods, fears of eviction by private landlords were also common. In regard to their physical status, 87% of the most distressed complained about their health, and almost half showed severe functional limitations of some kind. A review of their medical charts confirmed the accuracy of self-reports regarding physical impairment. Reports of diabetes, angina pectoris, neurological tremors, obesity and alcohol-related disorders were common. In fact, 16% had at least one psychiatric diagnosis entered into their chart, and an additional 11% had been identified as being alcoholics. While visiting the subjects' premises, the interviewers were in a position to observe overt signs and symptoms of distress: disheveled appearance, lassitude, anxiety, crying spells, and inertia. Quite obviously, the combination of current medical, economic, social and environmental circumstances seriously subverted attempts to maintain a sense of well-being in these "most distressed" subjects. INTERACTING VULNERABILITIES To illustrate interactions between developmental, structural and situational factors, some representative case studies are described below.

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Mrs. B. had a history of a particularly traumatic family breakdown many years previously in addition to facing assaults on her current life situation. She is 73 years of age and of African American and Chicano background. Her early life was spent on a share-cropping farm in Texas. While in her early teens, her father stabbed and killed her mother and two sisters. Mrs. B. also was wounded but recovered and subsequently raised her surviving younger siblings. With virtually no financial resources and little education, they lived well below the poverty line. She never married and had no children. Since her younger siblings are now deceased, she no longer maintains any family relationships. Reflecting her many losses, she is now almost totally isolated. She has very few friends and her holidays are spent alone. "I used to eat at my sisters' 'til they all got sick and died." Her major social contacts occur during intermittent church attendance. Among several ongoing assaults on her well-being, she fears being evicted by her landlord. "He is trying to get me out." She also lost her eligibility for SSI, leaving her financially impoverished. Ironically this loss of income resulted from the purchase of a burial plot in her hometown; that constituted an asset and technically disqualified her for SSL She spends her days attempting to regain her benefits. She is also involved in a pending lawsuit for asbestos poisoning, which she allegedly encountered working in shipyards during the war. In addition, she has initiated a second lawsuit after being struck by a car. Because of these concerns, she states, "Ain't lonesome - too busy with my affairs." Along with her many health problems, she has psychosomatic complaints. Her medical chart describes her as "a non-compliant somatizer" and lists the following conditions: "obesity, rheumatoid arthritis and clinical depression." Although she complains about the quality of her health care, the staff at the outpatient clinic appear to be her major source of support. When asked about her health she responded: " I ' m praying - ain't nothing help me but God".

Mr. T. illustrates a case of stable adaptation to a life-long crippling disease that was successful until a recent and precipitous decline in functioning. He is a 69 year-old white man with a graduate degree in business and a long history of employment with the federal government. He grew up in New York and had cerebral palsy since birth. When his physician moved to San Francisco 34 years ago, Mr. T. joined him, feeling he had few social ties to keep him in the East. His general health has only deteriorated seriously in recent years, when his disability progressed to the extent that his speech was barely intelligible. Because of his chronic health problems, he never married, although he had several long-term love affairs. While he had maintained some social ties until his physical decline, his current difficulty in speaking makes it almost impossible to socialize. " I ' v e become much less interested in people. It has become too much trouble. I have no visitors, and it is too difficult to go out." At the time of interview, he went out only once a week to attend a senior center and go to his bank. His main human contact was with a choreworker who came in three

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times a week to clean his apartment. With increasing social isolation and severe communication problems, his distress is high. His place is cluttered and poorly ventilated with a haze in the air from his continuous smoking. The only pleasure still available to him, he reports, is having a nightly martini while watching the evening news.

Others have had a long history of psychiatric problems after traumatic early years. For example, Mr. J. is a 67-year old man of Native American and Hispanic background. As a child, he was placed in an American Indian boarding school, and because of the long separations, he barely knew his parents. When he was fourteen, he went to live with his brother in Los Angeles. Shortly afterwards, he dropped out of school and worked in New Deal projects until he entered the military service in 1940. After a few months, he went A.W.O.L. because, "I got scared of going so far away." This desertion led to being placed in a state psychiatric hospital, an event which initiated a series of institutionalizations in mental hospitals. During some of these hospitalizations, he escaped and temporarily found work as a farm laborer umil he was reinstitutionalized. During the interview, he spoke of his life clearly and coherently and with a remarkable recollection of names and dates of the events in his unhappy life. He said all his relations were "gone with the wind," although he speaks to his brother annually by phone. The best times in his life, he reported, were the dances at the state hospitals. Despite his long history of mental hospitalizations, his medical chart lists no current psychiatric diagnoses. He now lives in a board and care home and spends his days in bed watching television.

Others voluntarily opted for a life independent of responsibilities to others. Mr. B. is a 74-year old white man who lives alone in a low rent, downtown hotel. During most of his career he worked as an electrician, and occasionally, an actor. He ran away from an unhappy home in his teens. Later he was married and divorced twice, but he has totally lost contact with ex-wives or children. He had been an alcoholic and a binge drinker for fifty years. Formerly he had a pattern of working on merchant ships for half a year to make money and then returning to San Francisco to "piss it away." At the time of the interview, he had not had a drink in seven years, and had had intermittent acting jobs until the previous year. His stamina was low, and he reported painful symptoms connected with chronic rheumatoid arthritis. Despite his poor health, he smoked two packs of cigarettes a day. The only time he left his room was to visit the doctor. He reported that his only friend is a young woman who delivers his "Meals on Wheels." When asked, "What makes you feel good about yourself?.," he responded, "Hardly anything except the stuff I

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dream up myself." In great pain due to arthritis, he looks forward to dying. "What the hell, what's the use of living. My life is over, but at least I don't have to deal with woman problems any more."

In some cases, distress appears to largely stem from situational stressors. Mrs. C. is an 80-year-old African American woman whose adaptation in late life is plagued by disruptive relocation and very poor health. Not surprisingly, she exhibits severe psychological distress, and her medical chart includes a diagnosis of clinical depression. She is currently surviving on the barest social, economic and health resources. She is also socially isolated. "My family they're all dead - my mama, my papa, everyone." She had been married in her late teens and widowed before thirty - "so long ago I can hardly remember it." Her son and a grandson died many years previously, and she subsequently lost contact with a second grandson. Before retiring because of illness, she worked as a domestic for forty years. Currently she subsists on SSI. Compounding her many losses, she was recently evicted from an apartment where she had resided for 30 years. This event was especially traumatic because it removed her from a familiar neighborhood, proximity to her church, and friends of long standing. Following her eviction she rented a room from an "odd" landlady. "I won't say nothing. I might get kicked out." The waiting list for senior housing is long, and she has resisted moving to general public housing. "That's where all the bad folks are." She has one male friend whom she sees every Saturday, when they go out to breakfast and then to his place to watch ballgames on television. She has no friends living near her current residence and spends her days by herself reading the Bible and singing hymns. She complains of loneliness and feels her doctor is her only confidante. Her declining physical health is a serious factor in her current distress. According to her medical charts, she was recently diagnosed as having cervical cancer and nodular shadows were seen on her chest X-ray. She and her doctors were most troubled about the possibility of a serious systemic disease. DISCUSSION AND CONCLUSIONS In this paper, we have described the developmental, medical, and social contexts in which psychological distress is likely to occur among poor older people. In interviews with 200 inner-city residents, 65 years and older, 21% were identified as having major psychological distress. This sample, in which two-thirds are African American, high proportions are not married, live alone and have no children in proximity. To compound these problems, complaints of economic problems, poor health, and disabilities were frequently reported. There were few gender differences in these characteristics, except that women were less distressed, a finding which may be related to women also being significantly more active in their churches. Significant racial differences were found in

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economic status, with African Americans reporting more problems. Psychological distress, however, was more common among whites who also were significantly less active in church participation. Correlations between distress and psychosomatic symptoms indicate that distress is more common among those with poorer health and more disability and less social and economic support in their life situation. Consequently it is likely that multiple vulnerabilities in the life situation make individuals more prone to distress. Racial differences found are more difficult to interpret and indicate the need for more research. African Americans are significantly less likely to be distressed, on a chi-square test a finding that may be linked to the fact that they are also likely to have more extensive social networks comprised of distant relatives, fictive kin, and fellow church members (Johnson and Barer 1990). A question was raised here about whether a levelling process occurs when members of both groups share a combination of circumstances linked to psychological distress. African Americans who are distressed share many characteristics with the distressed whites in the study. They are in the same cohort and share the same socioeconomic status. When they also share similar developmental vulnerabilities, limited opportunity structures, and contemporary provoking agents, evidence from this study suggests that they are also likely to experience psychological distress. Consequently when these events interact, cultural differences may be transcended. Using Bowlby's model (1988) of the Pathways to Depression, we singled out the most distressed for special analysis. These case studies illustrate how developmental and contemporary factors interact and result in distress. Among the early-life problems reported were family disorganization or family breakdown with the loss of mother or both parents, parental neglect or instability. Such factors often led to inadequate nurturing, fitful or abbreviated education, psychological or physical trauma, and problems in forming stable relationships. Over time, social structural deprivations led to limited aspirations and usually permanent lower class status. These patterns of instability continued in adolescence and early adulthood years, which were often marked by early marriage or casual unions, precocious parenthood, erratic employment, and family instability. By mid-life, these more distressed persons had experienced a series of losses: disconnections from spouse, children and friends, and dealing with deaths of older family members. For many, the advent of a chronic medical condition was encountered along with consequent decline in functioning; this situation in turn led to a marginal subsistence on SSI or social security. Consequently, a combination of medical, economic and psychological factors also contributed to increased isolation. Added to these developmental vulnerabilities and cumulative losses, factors in the current lives of this distressed group were uniformly negative. Upon reaching old age, we suggest that the loss of health and lowered functioning acted as provoking agents that, in combination with social losses, undermined

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well-being and led to distress and unhappiness. Frequently, as these individuals aged and their children matured, they experienced another series of losses with the deaths of their children, siblings, and friends. In instances where children resided in the vicinity, they usually were distracted by their own problems and hence unavailable to their aging parents. In the reverse direction, some parents avoided the problems connected to their children's disorganized lives by simply withdrawing from participation in family activities (Johnson and Barer 1990). It should be emphasized that almost 80% of the sample were living in comparative contentment despite facing the same pressures as the most distressed. They are successfully surviving into old age in a turbulent, inner-city environment. Such a finding indicates the need to study not only variables in the current situation but also the possible effects of earlier trauma. Adverse events in childhood which in conjunciton with life long economic deprivation and underclass status may interact with the provoking agents in the contemporary environment to result in psychological distress in late life. ACKNOWLEDGEMENTS This paper stems from research funding by the National Institute on Aging, RO1 AG06804. The authors wish to thank Barbara Barer for her comments on an earlier draft. REFERENCES Arling, G. 1987 Strain, Social Support, and Distress in Old Age. Journal of Gerontology 42:107-113. Berkman, L.F. and S.L. Syme 1979 Social Networks, Host Resistance and Mortality. Journal of Epidemiology 109: 186-204. Blazer, D., D. Hughes and L. George 1987 The Epidemiology of Depression in an Elderly Community Population. The Gerontologist 27: 275-280. Blazer, D. 1989 Depression in Late Life: An Update. In Annual Review in Gerontology and Geriatrics, P. Lawton, ed. Pp. 197-215. New York: Springer. Bowlby, J. 1982 Attachment and Loss Volume I: Attachment, second edition. New York: Basic Books. Bowlby, J. 1988 Developmental Psychiatry Comes of Age. American Journal of Psychiatry, 145: 1-10. Brown, G.W., A. Bilfulco and T.O. Harris 1987 Life Events, Vulnerability and Onset of Depression: Some Refinements. British Journal of Psychiatry 150: 30-42. Brown, G.W., and T. Harris 1978 Social Origins of Depression: A Study of Psychiatric Disorder in Women, London: Tavestock Publications. Faravelli, C.T. Webb, T.A. AmboneRi, F. Fonnesu, and A. Sessarego 1985 Prevalence of Early Life Traumatic Events in 31 Agoraphobic Patients with Panic Attacks. American Journal of Psychiatry 142: 1493-1494. Gatz, M. and M. Hurwicz 1990 Are Older People More Depressed? Cross-Sectional Data on the Center of Epidemiological Studies Depressive Scale Factors. Psychology and Aging 5: 284-290. Harris, T., G. Brown, and A. Bifulco 1987 Loss of Parent in Childhoood and Adult Psychiatric Disorder: The Role of Social Class Position and Premarital Pregnancy. Psychological Medicine 17: 163-183.

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