Social Class and Participation in Outpatient Care by Schizophrenics Gary Labreche, A.B. R. Jay Turner, Ph.D. Lawrence J. Zabo, M.A.
ABSTRACT: Based on a random sample of male schizophrenics, the relationship between social class and involvement in outpatient treatment was investigated. It was found that the likelihood of utilizing outpatient facilities is significantly related to social class status, lower-class patients being less often involved. Participation in outpatient treatment was also assessed in relation to severity of pathology, marital status, and hospitalization. The results are discussed in terms of self-selection and professional selectivity.
The past two decades have witnessed a rather radical change in the philosophy and treatment approaches of psychiatry. A major stimulus associated with this change has been the advent of effective psychotropic drugs making possible the serious consideration of treating the mentally ill within the community. Coupled with this was the development of the view that the patient should be maintained within the community to the maximum extent possible. Cole, et. al. (1962) have summed up the philosophy behind this approach by noting that: "These changes are motivated by the growing conviction that, if the patient's usual milieu is disrupted as little as possible, his degree of recovery will be enhanced." The combined effect of these elements has been to shift the locus of the problem away from the mental hospital and to the community. Hospitalization of the mentally ill is no longer typically measured in terms of one or more years but is more often a matter of months or even weeks. The discharged mental patient, therefore, is no longer a rarity. As Freeman and Simmons (I963) point out: "At the present time, it is no exaggeration to observe that the major problem in the field of mental illness is not the Mr. Labreche and Dr. Turner are associated with Temple University Community Mental Health Center, ~531 W. Tioga St., Philadelphia, Pa. ~914o. Mr. Zabo is with the California Department of Mental Hygiene. This paper derives from a study supported by grant MH-o92o 4 from the National Institute of Mental Health, R. Jay Turner, Ph.D., John Cummins, M.D., and Elmer Gardner, M.D., principal investigators. Computer analysis was supported, in part, by the National Science Foundation under Grant GP-I~-37. The authors are indebted to Dr. John Romano and the members of his department of psychiatry at the University of Rochester, without whose cooperation, assistance, and commitment to social psychiatric research, this study would not have been possible. Community Mental Health Journal, Vol. 5 (5), 1969
394
Labreche, Turner, and Zabo
395
hospitalized but the formerly hospitalized patient." In addition to the substantial numbers of formerly hospitalized patients now resident in the community, availability of effective drugs and early detection have probably kept an unknown number of mentally ill from ever being hospitalized. The community mental health movement attempts to establish facilities and develop modes of treatment that can provide maximum assistance to the patient while he remains within his home and community setting. These programs include such things as day and night hospitals, emergency treatment facilities in general hospitals, and outpatient clinics within community mental health centers. Since, under this scheme, the existing as well as new outpatient facilities ar~ expected to meet the needs of a wide array of patients, including the previously hospitalized and never hospitalized psychotic, the question arises as to what extent such a group can or will avail themselves of such treatment. The availability of such services would appear to be particularly pertinent in the case of schizophrenia. Two reasons can be listed for this. First, problems in attentiveness and communication are by definition associated with schizophrenic disorder, and adequate "motivation" and "ability to communicate" are often taken as necessary antecedents for acceptance into psychotherapy. Second, lower-class individuals are disproportionately represented in the schizophrenic population and the same factors of undermotivation and communication problems are often said to preclude the success of treatment for patients of lower socioeconomic status. Schizophrenics, therefore, particularly those of lower-class standing, are likely to be characterized by those very qualities that have been shown to lead to rejection by psychotherapists as untreatable (Cole, Branch, & Allison, 1962 ). In relation to social class position, it is reported that "... in a situation where the economic factor was held constant, acceptance for therapy and the character of subsequent clinical experience were related significantly to the patient's social class; the higher an individual's social class position, the more likely he was to be accepted for treatment, to be treated by highly trained personnel, and to be treated intensivelyover a long period" (Myers & Schaeffer,x954, P. 3o9)9 The same relationship between social class and acceptance for treatment was found in a ten-year follow-up study of the same population by Bean, Myers, and Pepper (1964). In this latter study, when only the schizophrenic subjects were considered, the relationship still held---eight times as many patients in classes I and II (upper) as class V (lower) were receiving outpatient care at the end of the ten-year period. Even if such professional selectivity were to be absent, however, there would remain a question of whether lower-class schizophrenics would present themselves for outpatient therapy or remain in it once begun. Reiff (1967) , among others, has persuasively argued that current mental health ideology may be so alien to members of the lower classes that they are unlikely to seek or tolerate programs associated with it.
396
Community Mental Health Journal
The utilization of outpatient facilities by persons diagnosed as schizophrenic is a relatively unexplored area. Although its importance in terms of implications for the planning of community mental health programs and for its role in mental hospital discharge procedure is clear, it is not known what proportion of schizophrenics use such facilities and what factors are associated with differential utilization. The purpose of this paper is to shed light on these questions. The paper considers the extent of utilization in relation to social class position and such additional variables as hospital experience, severity of pathology, and marital status. METHOD A sample of white males diagnosed as schizophrenic, ages 2o to 5o, was drawn from the Monroe County (New York) Psychiatric Case Register (Gardner, Miles, Iker, & Romano, ~963). Since its inception the register has recorded almost all (95%) psychiatric contacts that occur within the county. It thus provided a highly representative sampling base and, therein, a case-finding procedure quite independent of the variable of social position. An analysis of patterns of diagnostic assignment as reported on the register suggested that diagnostic tendency and the patients' social class position were also independent (Turner & Wagenfeld, ~967, p. ~o6). Of the cases meeting the sampling criteria, 2I 3 were ultimately interviewed. Although 82 appropriate cases (27%) were, for various reasons, lost to interview, prior analysis of this lost population (Turner & Wagenfeld, i967, p. II2) suggests that this sample mortality does not attach appreciable doubt to the findings to be presented here. The clinical status of included subjects ranged the full spectrum from those who were nearly asymptomatic to those who were severely impaired, and their total psychiatric experience varied from but a single outpatient visit to many lengthy hospitalizations. The register also supplied information on all periods of outpatient and inpatient care, providing a longitudinal record from three to six years' duration of all psychiatric experience for each subject. Other data sources were two separate and independent ratings by psychiatrists, a social worker's report of an interview with a family member, and a lengthy sociological questionnaire administered by a nonprofessional interviewer. As part of their evaluation process, interviewing psychiatrists assigned an overall pathology rating. This overall rating was made on a 12-point scale ranging from minimal impairment to marked impairment. To provide an estimate of pathology that was not materially influenced by knowledge of the patient's social functioning or history of hospitalization, a third psychiatrist with substantial clinical experience scored the 12-point pathology scale for each patient on the basis of the interviewing psychiatrist's symptom check list. These blind ratings are used in all analyses involving the variable of pathology. More detailed information on these data sources and interrater reliability can be found in Hetznecker, et. al. (2966).
Labreche, Turner, and Zabo
397
The measure of socioeconomic status employed was the Hollingshead Two Factor Index of Social Position (Hollingshead, ~952). For the purposes of this paper, a patient was considered to have been in outpatient care only if he was seen by a private psychiatrist or at a psychiatric clinic with a frequency equal to, or greater than, once per month, at some time during our three- to six-year follow-up period. A patient is considered to have been hospitalized only if he has ever had continuous inpatient care for more than 25 days. RESULTS Social Class Based upon the very liberal definition of involvement in outpatient care noted above, it was first determined that only 42% of our sample had ever utilized such services. The distributions of users and nonusers by social class position are shown in the right-hand portion of Table 2. Inspection of this table makes clear that the likelihood of being involved in outpatient care is by no means independent of one's social class position. The proportions involved by decreasing class status are .6~ 5 (I-III), .39 ~ (IV), and .329 (V). Thus these findings strongly support the hypothesis of a relationship between social class and involvement in outpatient care. TABLE 1 Outpatient care by social class for differing levels o[ pathology Overall pathology rating Total sample
Social class I-III
Minimal (z-5)
Moderate{6-9)
Marked(9-:12)
OP Care Some None
OP Care Some None
OP Care Some None
OP OP Care Care Some None
Total
8
7
15
:1o
9
3
32
zo
52
IV
:12
"~9
:I9
2:1
5
:16
36
56
92
V
5
9
I4
I4
3
a4
2a
47
69
a5
35
48
45
:17
43
9~
:1z3
z:13
Total
X 2 : :1.o6
X ~ ----~.oo
X 2 -----~7.o3
X 2 -- :1:1.31
P > .50
P > .50
P < .ooi
P < .005
It was suggested earlier that such a relationship might result from selfselection, professional selectivity, or both. In order for such interpretations of the observed relationship to remain plausible, however, several additional variables must be taken into account. It is known that time spent in hospital is related to how impaired an individual is (Turner & Zabo, ~967),
398
Community Mental Health Journal
to his social class (Hollingshead & Redlich, i958; Myers, Bean & Pepper, 1965; Hardt & Feinhandler, 2959) and to marital status (Farina, Garmezy & Barry, i963; Sherman, Mosely, Ging & Bookbinder, 2964; Norris, 2956). There is reason to suggest, therefore, that experience with inpatient care, severity of disorder, and marital status may be related to the occurrence of outpatient treatment.
Severity of Pathology Table 2 also displays the relationship between social class and participation in outpatient treatment for varying levels of psychiatric impairment. Looking first at the minimally impaired group, the shift to lesser contact with lower-class status appears to hold since the percent involved in outpatient care drops from 53.3% for social classes I-III, through 38.7% at level IV, to 35.7% at social class V. These differences notwithstanding, however, a chi-square analysis of the frequencies shown offers no evidence of any relationship between social class and involvement in outpatient care for this group. Much the same can be said for the moderately impaired category. Although the percent utilizing outpatient services drops from 60% in class I-III to approximately 5o~o in the cases of social classes IV and V, the chi-square evaluation again fails to support the hypothesized relationship. When the markedly impaired subjects are examined, differences in utilization of outpatient facilities by social classes become striking. Of those in the highest status grouping, 75% have received outpatient treatment while 24% of the class IV individuals and only 22 % of those in class V have been so involved. The chi-square value calculated from these data is 27.o3 (2 d.f.) which is significant at the .oo2 level. In accomplishing these analyses it was noted that several subjects, particularly in the lower social classes, had been hospitalized for a significant portion of the three- to six-year follow-up period. Since it is obvious that being in hospital precludes involvement in outpatient treatment, we questioned whether differential opportunity associated with reduced time in the community might be biasing our results. To control for this the analysis was repeated, including only those subjects who had spent more than 50% of the follow-up period in the community. The resulting percentages participating in outpatient treatment by decreasing class status were 8o~o, 27%, and 22% respectively. Thus the finding holds and the conclusion is allowed that, at least for the severely ill, the probability of being involved in outpatient care is significantly related to social class position. The relationship of severity of pathology itself to outpatient care is also of interest. Inspection of the horizontal marginals in Table I indicates that for the total sample the likelihood of involvement in outpatient treatment is highest among the moderately impaired and lowest for the markedly impaired group. Looking within social class levels, this relationship ob-
Labreche, Turner, and Zabo
390
tains for both classes IV and V, but is importantly different for the higher social class category. For this group there appears to be a direct relationship between severity of pathology and the likelihood of outpatient care. No doubt there are several possible explanations for these observations. What they suggest to the present authors, however, is that when a higher status individual becomes severely disordered, recourse to outpatient treatment rather than inpatient care is more likely than for lower status individuals. This may result from a differential willingness on the part of family members to accept the hospitalization option or a tendency on the part of psychiatric screening personnel to more readily hospitalize the severely disordered lower-class patient rather than to accept or refer him for outpatient treatment. Marital Status
It was suggested earlier that since marital status is known to be related to the probability and length of hospitalization, this factor may also play a role in the determination of outpatient participation. To check on this possibility married patients were compared with single or previously married patients in terms of whether they had been or were currently involved in outpatient treatment. These data are shown in the extreme right hand portion of Table 2. Inspection of the frequencies shown and the computed chi-square value of only .66 make clear that the probability of being involved in outpatient treatment is about equal for married and nonmarried patients. There is, in short, no evidence to suggest that marital status is related to outpatient participation when the total sample is considered. The remainder of Table 2 tests the possibility that marital status may be differentially related to such involvement at different class levels. These analyses provide no suggestion of an interaction effect and the conclusion follows that marital status is of little consequence either across or within TABLE 2 O u t p a t i e n t care by marital status a n d social class level
Marital status
I-III
Social class IV
V
Total sample
OP Care Some None
OP Care Some None
OP Care Some None
OP Care Some None Total
Married Single Total
21 z6 Iz 4 32 2o X2 -~- 5.24 P ~ .25
2z z5 36 X2 ~
3z 25 56 .o6
P > .75
zo I2 22 X2 =
17 30 47 .53
P ~ .25
zz6 97 zi3
64 38 59 9~ I23 X2 ~ .66 52
P > .25
~6 97 2-r3
400
Community Mental Health Journal
social status categories. To check for a second order interaction this same table was run additionally subdivided by severity of pathology. Although it was again impossible to find evidence of an interaction effect, it should be noted that this additional subdivision produced extremely small cell frequencies, thus precluding any firm conclusions on this matter. Hospitalization
An additional issue we wished to address was whether the pattern of social class-outpatient treatment relationships differed for subjects who had had a significant inpatient experience (a continuous hospitalization greater than z 5 days) and those who had not. These data are presented in Table 3. The percentage of subjects involved in outpatient TABLE 3 Outpatient care by hospitalization and social class level
Hospitalization
I-III
Social class IV
V
OP Care Some None
OP Care Some None
OP Care Some None Total
Ever Never Total
z7 z5 32
9 zz 2o
23 z3 36
35 2z 56
z4 8 22
33 z4 47
z3z 82 2x3
treatment by decreasing class levels are, for the hospitalized group, 65.4%, 3 9 . 7 % , and 29.8 % and for the never-hospitalized group 5 7 . 7 % , 38.2%, and 36.4%, respectively. The pattern of decreasing utilization with the decreasing social class level is thus consistent for both groups. It is interesting to note, however, that while in both classes I-III and IV a greater percentage of those who had been hospitalized participated in outpatient treatment, the reverse is true in the case of class V. In the class V group, patients who had never had a significant inpatient experience were more likely to be involved in outpatient care than their counterparts who had been hospitalized. These differences, however, are not great and interpretation should be made with caution. If social class is ignored, the proportion of the hospitalized and never-hospitalized groups who had participated in outpatient treatment are essentially equivalent. SUMMARY AND CONCLUSIONS The general purpose of this paper is to investigate the relationship between social class position and involvement in outpatient treatment. Findings support those of prior research that the probability of
Labreche, Turner, and Zabo
401
utilizing outpatient facilities is significantly related to social class position --lower status patients being less likely to be involved. In a step beyond those taken in earlier studies, this relationship was inspected for groups of varying severity of disorder. Although the same trend could be observed at each of the three levels of pathology considered, statistical analyses supported the relationship only within the severely impaired category. This finding and the differential overall relationship between severity of pathology and the occurrence of outpatient care at different class levels is consistent with the notion that some form of class-related selectivity operates. In considering the possible role of professional selectivity, it should be noted that, if such selectivity is operating, it may have at least two sources. One source, as suggested earlier, may be a bias among practitioners arising from the real or imagined tendency for lower-class individuals to lack the motivation or conceptual skills required for effective psychotherapy. A second source may be the, presumably, objective judgment that at least temporary removal of the patient from his lower-class milieu is desirable, or that the patient's family is unable or unwilling to provide the support and supervision he requires to maintain himself within the community. The question of whether marital status may be related to involvement in outpatient care was also assessed. No evidence could be found for such a relationship either within or across social status categories. It appears that whatever influence family members or relatives may exert upon the patient or upon treatment facilities in relation to outpatient participation, it does not differ materially for married and nonmarried subjects. The relationship of social class to outpatient involvement was also compared for subjects who have had inpatient experience and those who have not. Although the relationships within these categories were consistent with that observed for the total sample, it was noted that in classes I-III and IV subjects with inpatient experience were more often involved in outpatient care while the reverse was true in class V. Among lower status patients, those who had never been hospitalized participated more often in outpatient treatment than their class counterparts who had been hospitalized. REFERENCES Bean, L. L., Myers, J. K., and Pepper, M. Social class and schizophrenia: a ten year follow-up. In A. B. Shostak and W. Gomberg (Eds.), Blue-collar world: studies of the American worker. Englewood Cliffs: Prentice-Hall, ~964. Pp. 381-39~. Cole, ~Nyla J., Branch, C. H. H., and Allison, R. B. Some relationships between social class and the practice of dynamic psychotherapy. American Journal of Psychiatry, ~962, i~8, ~oo4-~o22. Farina, A., Garmezy, N., and Barry, H. Relationship of marital status to incidence and prognosis of schizophrenia. Journal of Abnormal and Social Psychology, 2963, 67, 624 63o. Freeman, H. E., and Simmons, O. G. The mental patient comes home. New York: John Wiley, 2963 .
402
Community Mental Health Journal
Gardner, E. A., Miles, H. C., Iker, H. P., and Romano, J. A cumulative register of psychiatric services in a community. American Journal of Public Health, ~963, 53, ~269-I277. Hardt, R., and Feinhandler, S. Social class and mental hospitalization prognosis. American Sociological Review, 1959, 24, 812-8ax. Hetznecker, W., Gardner, E. A., Odoroff, C. L., and Turner, R. J. Field survey methods in psychiatry: a symptom check list, mental status and clinical status scales for evaluation of psychiatric impairment. Archives of General Psychiatry, x966, 15, 427 438 9 Hollingshead, A. B. Two-factor index of social position. New Haven, i952. (mimeo.) Hollingshead, A. B., and Redlich, F. C. Social class and mental illness. New York: John Wiley, x958. Myers, J. K., Bean, L. L., and Pepper, M. Social class and psychiatric disorders: a tenyear follow-up. Journal of Health and Human Behavior, ~956, 6, 74-79. Myers, J. K., and Schaeffer, L. Social stratification and psychiatric practice: a study of an outpatient clinic. American Sociological Review, 1954, I9, 3o7-3xo. Norris, Vera. A statistical study of the influence of marriage on the hospital care of the mentally sick. ]ournaI of Mental Science, i956 , zo2,467-486. Rieff, R. Mental health manpower and institutional change. In E. C0wan, E. A. Gardner, and M. Zax (Eds.), Emergent approaches to mental health problems. New York: Appleton-Century-Crofts, I967. Sherman, L. J., Moseley, E. C., Ging, Rosalie, and Bookbinder, L. J. Prognosis in schizophrenia. Archives of General Psychiatry, I964, lo, ~23-~3o. Turner, R. J., and Wagenfeld, M. O. Occupational mobility and schizophrenia: an assessment of the social causation and social selection hypotheses. American Sociological Review, i967, 32 , io4-i13 . Turner, R. J., and Zabo, L. J. Social competence and schizophrenia: an investigation and critique. ]ournat of Health and Social Behavior, x967, 8.
ABSTRACT: Based on a random sample of male schizophrenics, the relationship between social class and involvement in outpatient treatment was investigated. It was found that the likelihood of utilizing outpatient facilities is significantly related to social class status, lower-class patients being less often involved. Participation in outpatient treatment was also assessed in relation to severity of pathology, marital status, and hospitalization. The results are discussed in terms of self-selection and professional selectivity.
The past two decades have witnessed a rather radical change in the philosophy and treatment approaches of psychiatry. A major stimulus associated with this change has been the advent of effective psychotropic drugs making possible the serious consideration of treating the mentally ill within the community. Coupled with this was the development of the view that the patient should be maintained within the community to the maximum extent possible. Cole, et. al. (1962) have summed up the philosophy behind this approach by noting that: "These changes are motivated by the growing conviction that, if the patient's usual milieu is disrupted as little as possible, his degree of recovery will be enhanced." The combined effect of these elements has been to shift the locus of the problem away from the mental hospital and to the community. Hospitalization of the mentally ill is no longer typically measured in terms of one or more years but is more often a matter of months or even weeks. The discharged mental patient, therefore, is no longer a rarity. As Freeman and Simmons (I963) point out: "At the present time, it is no exaggeration to observe that the major problem in the field of mental illness is not the Mr. Labreche and Dr. Turner are associated with Temple University Community Mental Health Center, ~531 W. Tioga St., Philadelphia, Pa. ~914o. Mr. Zabo is with the California Department of Mental Hygiene. This paper derives from a study supported by grant MH-o92o 4 from the National Institute of Mental Health, R. Jay Turner, Ph.D., John Cummins, M.D., and Elmer Gardner, M.D., principal investigators. Computer analysis was supported, in part, by the National Science Foundation under Grant GP-I~-37. The authors are indebted to Dr. John Romano and the members of his department of psychiatry at the University of Rochester, without whose cooperation, assistance, and commitment to social psychiatric research, this study would not have been possible. Community Mental Health Journal, Vol. 5 (5), 1969
394
Labreche, Turner, and Zabo
395
hospitalized but the formerly hospitalized patient." In addition to the substantial numbers of formerly hospitalized patients now resident in the community, availability of effective drugs and early detection have probably kept an unknown number of mentally ill from ever being hospitalized. The community mental health movement attempts to establish facilities and develop modes of treatment that can provide maximum assistance to the patient while he remains within his home and community setting. These programs include such things as day and night hospitals, emergency treatment facilities in general hospitals, and outpatient clinics within community mental health centers. Since, under this scheme, the existing as well as new outpatient facilities ar~ expected to meet the needs of a wide array of patients, including the previously hospitalized and never hospitalized psychotic, the question arises as to what extent such a group can or will avail themselves of such treatment. The availability of such services would appear to be particularly pertinent in the case of schizophrenia. Two reasons can be listed for this. First, problems in attentiveness and communication are by definition associated with schizophrenic disorder, and adequate "motivation" and "ability to communicate" are often taken as necessary antecedents for acceptance into psychotherapy. Second, lower-class individuals are disproportionately represented in the schizophrenic population and the same factors of undermotivation and communication problems are often said to preclude the success of treatment for patients of lower socioeconomic status. Schizophrenics, therefore, particularly those of lower-class standing, are likely to be characterized by those very qualities that have been shown to lead to rejection by psychotherapists as untreatable (Cole, Branch, & Allison, 1962 ). In relation to social class position, it is reported that "... in a situation where the economic factor was held constant, acceptance for therapy and the character of subsequent clinical experience were related significantly to the patient's social class; the higher an individual's social class position, the more likely he was to be accepted for treatment, to be treated by highly trained personnel, and to be treated intensivelyover a long period" (Myers & Schaeffer,x954, P. 3o9)9 The same relationship between social class and acceptance for treatment was found in a ten-year follow-up study of the same population by Bean, Myers, and Pepper (1964). In this latter study, when only the schizophrenic subjects were considered, the relationship still held---eight times as many patients in classes I and II (upper) as class V (lower) were receiving outpatient care at the end of the ten-year period. Even if such professional selectivity were to be absent, however, there would remain a question of whether lower-class schizophrenics would present themselves for outpatient therapy or remain in it once begun. Reiff (1967) , among others, has persuasively argued that current mental health ideology may be so alien to members of the lower classes that they are unlikely to seek or tolerate programs associated with it.
396
Community Mental Health Journal
The utilization of outpatient facilities by persons diagnosed as schizophrenic is a relatively unexplored area. Although its importance in terms of implications for the planning of community mental health programs and for its role in mental hospital discharge procedure is clear, it is not known what proportion of schizophrenics use such facilities and what factors are associated with differential utilization. The purpose of this paper is to shed light on these questions. The paper considers the extent of utilization in relation to social class position and such additional variables as hospital experience, severity of pathology, and marital status. METHOD A sample of white males diagnosed as schizophrenic, ages 2o to 5o, was drawn from the Monroe County (New York) Psychiatric Case Register (Gardner, Miles, Iker, & Romano, ~963). Since its inception the register has recorded almost all (95%) psychiatric contacts that occur within the county. It thus provided a highly representative sampling base and, therein, a case-finding procedure quite independent of the variable of social position. An analysis of patterns of diagnostic assignment as reported on the register suggested that diagnostic tendency and the patients' social class position were also independent (Turner & Wagenfeld, ~967, p. ~o6). Of the cases meeting the sampling criteria, 2I 3 were ultimately interviewed. Although 82 appropriate cases (27%) were, for various reasons, lost to interview, prior analysis of this lost population (Turner & Wagenfeld, i967, p. II2) suggests that this sample mortality does not attach appreciable doubt to the findings to be presented here. The clinical status of included subjects ranged the full spectrum from those who were nearly asymptomatic to those who were severely impaired, and their total psychiatric experience varied from but a single outpatient visit to many lengthy hospitalizations. The register also supplied information on all periods of outpatient and inpatient care, providing a longitudinal record from three to six years' duration of all psychiatric experience for each subject. Other data sources were two separate and independent ratings by psychiatrists, a social worker's report of an interview with a family member, and a lengthy sociological questionnaire administered by a nonprofessional interviewer. As part of their evaluation process, interviewing psychiatrists assigned an overall pathology rating. This overall rating was made on a 12-point scale ranging from minimal impairment to marked impairment. To provide an estimate of pathology that was not materially influenced by knowledge of the patient's social functioning or history of hospitalization, a third psychiatrist with substantial clinical experience scored the 12-point pathology scale for each patient on the basis of the interviewing psychiatrist's symptom check list. These blind ratings are used in all analyses involving the variable of pathology. More detailed information on these data sources and interrater reliability can be found in Hetznecker, et. al. (2966).
Labreche, Turner, and Zabo
397
The measure of socioeconomic status employed was the Hollingshead Two Factor Index of Social Position (Hollingshead, ~952). For the purposes of this paper, a patient was considered to have been in outpatient care only if he was seen by a private psychiatrist or at a psychiatric clinic with a frequency equal to, or greater than, once per month, at some time during our three- to six-year follow-up period. A patient is considered to have been hospitalized only if he has ever had continuous inpatient care for more than 25 days. RESULTS Social Class Based upon the very liberal definition of involvement in outpatient care noted above, it was first determined that only 42% of our sample had ever utilized such services. The distributions of users and nonusers by social class position are shown in the right-hand portion of Table 2. Inspection of this table makes clear that the likelihood of being involved in outpatient care is by no means independent of one's social class position. The proportions involved by decreasing class status are .6~ 5 (I-III), .39 ~ (IV), and .329 (V). Thus these findings strongly support the hypothesis of a relationship between social class and involvement in outpatient care. TABLE 1 Outpatient care by social class for differing levels o[ pathology Overall pathology rating Total sample
Social class I-III
Minimal (z-5)
Moderate{6-9)
Marked(9-:12)
OP Care Some None
OP Care Some None
OP Care Some None
OP OP Care Care Some None
Total
8
7
15
:1o
9
3
32
zo
52
IV
:12
"~9
:I9
2:1
5
:16
36
56
92
V
5
9
I4
I4
3
a4
2a
47
69
a5
35
48
45
:17
43
9~
:1z3
z:13
Total
X 2 : :1.o6
X ~ ----~.oo
X 2 -----~7.o3
X 2 -- :1:1.31
P > .50
P > .50
P < .ooi
P < .005
It was suggested earlier that such a relationship might result from selfselection, professional selectivity, or both. In order for such interpretations of the observed relationship to remain plausible, however, several additional variables must be taken into account. It is known that time spent in hospital is related to how impaired an individual is (Turner & Zabo, ~967),
398
Community Mental Health Journal
to his social class (Hollingshead & Redlich, i958; Myers, Bean & Pepper, 1965; Hardt & Feinhandler, 2959) and to marital status (Farina, Garmezy & Barry, i963; Sherman, Mosely, Ging & Bookbinder, 2964; Norris, 2956). There is reason to suggest, therefore, that experience with inpatient care, severity of disorder, and marital status may be related to the occurrence of outpatient treatment.
Severity of Pathology Table 2 also displays the relationship between social class and participation in outpatient treatment for varying levels of psychiatric impairment. Looking first at the minimally impaired group, the shift to lesser contact with lower-class status appears to hold since the percent involved in outpatient care drops from 53.3% for social classes I-III, through 38.7% at level IV, to 35.7% at social class V. These differences notwithstanding, however, a chi-square analysis of the frequencies shown offers no evidence of any relationship between social class and involvement in outpatient care for this group. Much the same can be said for the moderately impaired category. Although the percent utilizing outpatient services drops from 60% in class I-III to approximately 5o~o in the cases of social classes IV and V, the chi-square evaluation again fails to support the hypothesized relationship. When the markedly impaired subjects are examined, differences in utilization of outpatient facilities by social classes become striking. Of those in the highest status grouping, 75% have received outpatient treatment while 24% of the class IV individuals and only 22 % of those in class V have been so involved. The chi-square value calculated from these data is 27.o3 (2 d.f.) which is significant at the .oo2 level. In accomplishing these analyses it was noted that several subjects, particularly in the lower social classes, had been hospitalized for a significant portion of the three- to six-year follow-up period. Since it is obvious that being in hospital precludes involvement in outpatient treatment, we questioned whether differential opportunity associated with reduced time in the community might be biasing our results. To control for this the analysis was repeated, including only those subjects who had spent more than 50% of the follow-up period in the community. The resulting percentages participating in outpatient treatment by decreasing class status were 8o~o, 27%, and 22% respectively. Thus the finding holds and the conclusion is allowed that, at least for the severely ill, the probability of being involved in outpatient care is significantly related to social class position. The relationship of severity of pathology itself to outpatient care is also of interest. Inspection of the horizontal marginals in Table I indicates that for the total sample the likelihood of involvement in outpatient treatment is highest among the moderately impaired and lowest for the markedly impaired group. Looking within social class levels, this relationship ob-
Labreche, Turner, and Zabo
390
tains for both classes IV and V, but is importantly different for the higher social class category. For this group there appears to be a direct relationship between severity of pathology and the likelihood of outpatient care. No doubt there are several possible explanations for these observations. What they suggest to the present authors, however, is that when a higher status individual becomes severely disordered, recourse to outpatient treatment rather than inpatient care is more likely than for lower status individuals. This may result from a differential willingness on the part of family members to accept the hospitalization option or a tendency on the part of psychiatric screening personnel to more readily hospitalize the severely disordered lower-class patient rather than to accept or refer him for outpatient treatment. Marital Status
It was suggested earlier that since marital status is known to be related to the probability and length of hospitalization, this factor may also play a role in the determination of outpatient participation. To check on this possibility married patients were compared with single or previously married patients in terms of whether they had been or were currently involved in outpatient treatment. These data are shown in the extreme right hand portion of Table 2. Inspection of the frequencies shown and the computed chi-square value of only .66 make clear that the probability of being involved in outpatient treatment is about equal for married and nonmarried patients. There is, in short, no evidence to suggest that marital status is related to outpatient participation when the total sample is considered. The remainder of Table 2 tests the possibility that marital status may be differentially related to such involvement at different class levels. These analyses provide no suggestion of an interaction effect and the conclusion follows that marital status is of little consequence either across or within TABLE 2 O u t p a t i e n t care by marital status a n d social class level
Marital status
I-III
Social class IV
V
Total sample
OP Care Some None
OP Care Some None
OP Care Some None
OP Care Some None Total
Married Single Total
21 z6 Iz 4 32 2o X2 -~- 5.24 P ~ .25
2z z5 36 X2 ~
3z 25 56 .o6
P > .75
zo I2 22 X2 =
17 30 47 .53
P ~ .25
zz6 97 zi3
64 38 59 9~ I23 X2 ~ .66 52
P > .25
~6 97 2-r3
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social status categories. To check for a second order interaction this same table was run additionally subdivided by severity of pathology. Although it was again impossible to find evidence of an interaction effect, it should be noted that this additional subdivision produced extremely small cell frequencies, thus precluding any firm conclusions on this matter. Hospitalization
An additional issue we wished to address was whether the pattern of social class-outpatient treatment relationships differed for subjects who had had a significant inpatient experience (a continuous hospitalization greater than z 5 days) and those who had not. These data are presented in Table 3. The percentage of subjects involved in outpatient TABLE 3 Outpatient care by hospitalization and social class level
Hospitalization
I-III
Social class IV
V
OP Care Some None
OP Care Some None
OP Care Some None Total
Ever Never Total
z7 z5 32
9 zz 2o
23 z3 36
35 2z 56
z4 8 22
33 z4 47
z3z 82 2x3
treatment by decreasing class levels are, for the hospitalized group, 65.4%, 3 9 . 7 % , and 29.8 % and for the never-hospitalized group 5 7 . 7 % , 38.2%, and 36.4%, respectively. The pattern of decreasing utilization with the decreasing social class level is thus consistent for both groups. It is interesting to note, however, that while in both classes I-III and IV a greater percentage of those who had been hospitalized participated in outpatient treatment, the reverse is true in the case of class V. In the class V group, patients who had never had a significant inpatient experience were more likely to be involved in outpatient care than their counterparts who had been hospitalized. These differences, however, are not great and interpretation should be made with caution. If social class is ignored, the proportion of the hospitalized and never-hospitalized groups who had participated in outpatient treatment are essentially equivalent. SUMMARY AND CONCLUSIONS The general purpose of this paper is to investigate the relationship between social class position and involvement in outpatient treatment. Findings support those of prior research that the probability of
Labreche, Turner, and Zabo
401
utilizing outpatient facilities is significantly related to social class position --lower status patients being less likely to be involved. In a step beyond those taken in earlier studies, this relationship was inspected for groups of varying severity of disorder. Although the same trend could be observed at each of the three levels of pathology considered, statistical analyses supported the relationship only within the severely impaired category. This finding and the differential overall relationship between severity of pathology and the occurrence of outpatient care at different class levels is consistent with the notion that some form of class-related selectivity operates. In considering the possible role of professional selectivity, it should be noted that, if such selectivity is operating, it may have at least two sources. One source, as suggested earlier, may be a bias among practitioners arising from the real or imagined tendency for lower-class individuals to lack the motivation or conceptual skills required for effective psychotherapy. A second source may be the, presumably, objective judgment that at least temporary removal of the patient from his lower-class milieu is desirable, or that the patient's family is unable or unwilling to provide the support and supervision he requires to maintain himself within the community. The question of whether marital status may be related to involvement in outpatient care was also assessed. No evidence could be found for such a relationship either within or across social status categories. It appears that whatever influence family members or relatives may exert upon the patient or upon treatment facilities in relation to outpatient participation, it does not differ materially for married and nonmarried subjects. The relationship of social class to outpatient involvement was also compared for subjects who have had inpatient experience and those who have not. Although the relationships within these categories were consistent with that observed for the total sample, it was noted that in classes I-III and IV subjects with inpatient experience were more often involved in outpatient care while the reverse was true in class V. Among lower status patients, those who had never been hospitalized participated more often in outpatient treatment than their class counterparts who had been hospitalized. REFERENCES Bean, L. L., Myers, J. K., and Pepper, M. Social class and schizophrenia: a ten year follow-up. In A. B. Shostak and W. Gomberg (Eds.), Blue-collar world: studies of the American worker. Englewood Cliffs: Prentice-Hall, ~964. Pp. 381-39~. Cole, ~Nyla J., Branch, C. H. H., and Allison, R. B. Some relationships between social class and the practice of dynamic psychotherapy. American Journal of Psychiatry, ~962, i~8, ~oo4-~o22. Farina, A., Garmezy, N., and Barry, H. Relationship of marital status to incidence and prognosis of schizophrenia. Journal of Abnormal and Social Psychology, 2963, 67, 624 63o. Freeman, H. E., and Simmons, O. G. The mental patient comes home. New York: John Wiley, 2963 .
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Gardner, E. A., Miles, H. C., Iker, H. P., and Romano, J. A cumulative register of psychiatric services in a community. American Journal of Public Health, ~963, 53, ~269-I277. Hardt, R., and Feinhandler, S. Social class and mental hospitalization prognosis. American Sociological Review, 1959, 24, 812-8ax. Hetznecker, W., Gardner, E. A., Odoroff, C. L., and Turner, R. J. Field survey methods in psychiatry: a symptom check list, mental status and clinical status scales for evaluation of psychiatric impairment. Archives of General Psychiatry, x966, 15, 427 438 9 Hollingshead, A. B. Two-factor index of social position. New Haven, i952. (mimeo.) Hollingshead, A. B., and Redlich, F. C. Social class and mental illness. New York: John Wiley, x958. Myers, J. K., Bean, L. L., and Pepper, M. Social class and psychiatric disorders: a tenyear follow-up. Journal of Health and Human Behavior, ~956, 6, 74-79. Myers, J. K., and Schaeffer, L. Social stratification and psychiatric practice: a study of an outpatient clinic. American Sociological Review, 1954, I9, 3o7-3xo. Norris, Vera. A statistical study of the influence of marriage on the hospital care of the mentally sick. ]ournaI of Mental Science, i956 , zo2,467-486. Rieff, R. Mental health manpower and institutional change. In E. C0wan, E. A. Gardner, and M. Zax (Eds.), Emergent approaches to mental health problems. New York: Appleton-Century-Crofts, I967. Sherman, L. J., Moseley, E. C., Ging, Rosalie, and Bookbinder, L. J. Prognosis in schizophrenia. Archives of General Psychiatry, I964, lo, ~23-~3o. Turner, R. J., and Wagenfeld, M. O. Occupational mobility and schizophrenia: an assessment of the social causation and social selection hypotheses. American Sociological Review, i967, 32 , io4-i13 . Turner, R. J., and Zabo, L. J. Social competence and schizophrenia: an investigation and critique. ]ournat of Health and Social Behavior, x967, 8.
