‘A proposal for research in the epidemiology of psychiatric disorders’,by Alexander H Leighton

[page 128]

General Aims

The central research aim is a partial examination of the relationship between psychiatric disorders in the social environment for the purpose of evaluating the general proposition that social and cultural factors are causal forces. The desire is to discover the distribution of psychiatric disorders in communities in relation to social organization and cultural patterns and to see if, in this frame of reference, significant differences can be detected between pathological and normal individuals.

It is evident from the beginning that there is no way in which the general proposition may be directly and clearly checked. In consequence the work must be organized in terms of more specific dependent hypotheses which can be tested. While no one of these tests may be crucial to the general theory, they must be selected in such a way that the cumulative results clarify the basic proposition. It would be premature at this point to state with certainty which dependent hypotheses will actually be employed, but for the sake of illustration some tentative examples may be cited. Thus, one could say that psychiatric disorders are fostered by:

1. Broken homes.

2. Social groups in which values are uncertain and conflicting.

3. Rapid technological change.

4. Social groups in which there is a wide gap between expectation and achievement.

5. Social groups in which there is fear and uncertainty in regard to the future.

[p. 129]

A Proposal for Research

It is hoped that the upshot of the research will have value on a number of counts that range from the pragmatic to the conceptual:

1. Increased insight regarding the significance of the social environment as a contributor to psychiatric disorders.

2. Indications as to which type of stress in the social environment are most important in the production of psychiatric disorders.

3. Indications as to which types of psychiatric disorders are most closely tied to factors in the social environment.

4. Knowledge regarding how normal people handle the situational factors which have an important causal or determinant role in pathological cases.

5. Illumination regarding the relationship between personality formation and social environment.

6. The uncovering of leads for further research in the etiology of psychiatric disorder – the definition of problems.

Orientation

As employed here “the epidemiology of psychiatric disorders” refers to a theory which assumes the existence of two sets of factors in the human environment: those that create or foster psychiatric disorders and those that create or foster their absence. By psychiatric disorders are meant those conditions commonly called psychoses, and psychoneuroses together with some other possibly related patterns of behavior. It is realized that the boundary between mental disease and mental health is difficult to distinguish, but it is assumed that enough cases exist well back on either side from this border so that they can be recognized, studied and compared by means of existing technical tools.

Most of our ideas about causes and determinants in mental disease are based on cases of poor mental health, that is pathology, without the corrective effect of equally intensive and extensive study of normals. The reasons for this are practical and obvious but the need for such work remains. In all other branches of medicine, pathology is paired with a corresponding [p. 130] division of physiology, which is to say, the study of normal function.

This suggests the desirability of matching a population of psychiatric cases with normal controls. The psychiatric cases could be worked up according to a set of established procedures and a comparable number of normal individuals could be studied in the same manner. The results could then be analyzed for the differences they revealed in the relationship of personality to social environment in the two populations.

Although this is a simple enough idea, it becomes extremely complex as soon as one begins to think about putting it into action. The number of variables involved in any one case are very large and each study of an individual is certain to be time-consuming. If one begins to think of studies in any quantity, he soon finds himself in the middle of a project of vast expense and requiring many years of observation and more years of analysis. It becomes evident that short cuts must be devised, but short cuts that will still lead to meaningful results.

One step in the direction of reducing the number of variables and of increasing the opportunities for verification is to limit all the personality studies, both pathological and normal, to one community or a set of closely interrelated communities. This effect is further enhanced if both types of cases are studied at approximately the same time. By this means we can have more environmental constants and more bases for comparing the background and experiences of the individuals and hence more opportunity to draw general conclusions. In many instances such data as life stories will cross-check each other and provide multiple evidence regarding certain events and circumstances that are important in the development and reactions of personality.

Values of Concentrating Studies in One Community [was footnote, pp. 130–131]

1. We are studying a set of complex interrelationships. Therefore they are more meaningful and revealing if studied where they occur rather than studied as different aspects in different communities and put together by extrapolation. For instance, studying abnormals in one place, normals in another, adults in this community, children in that, etc. (See list page 128 [under General Aims])

2. The work D. C. Leighton ¹ and I did with personality studies in two small “native” communities demonstrated the additive effect of having these studies in one place. For example, pictures of family constellations and patterns emerged which could never have been obtained except by viewing them from multiple observation points by means of personality studies of different people who were members of these constellations. The same applied to occupations, religious groups and to cliques.

3. It is only by working in one community that the specific information and methods of anthropology, social psychology, and other social sciences can be brought to bear.

4. As compared to an institutional study such as a college, the relationships in a community are to a far greater degree life-long and life-determining. A community is more of an organic entity for more of its members – the whole of life is lived there (not a part of it), it is not highly conditioned by one set of aims such as education (or earning a living as in a plant) but is concerned with the interplay and balancing of all the live social forces.

5. Later research can build on earlier research. First work can form a base line for later comparisons and thus grow more valuable and meaningful with time. This is particularly relevant from the conceptual point of view since it is the dynamic processes that extend through time that are the greatest blank in our knowledge of social process.

[p. 131]

A Proposal for Research

If the community is one in which the cultural patterns and social organization (e.g. values, beliefs, customs, leadership and class structures, status positions, sources of psychological stress) have been ascertained by the techniques of the other social sciences, then the chances of uncovering significant leads concerning the relationship of social environment and personality disorder will be greatly increased. It should be possible to evaluate the established theories in this field by seeing whether or not there is a higher frequency of mental ill-health where theory suggests it should be; and correspondingly, whether or not there is a lower incidence of ill-health where theory says it should be low.

This means that the smaller the community, the more manageable the research. On the other hand, such an advantage must be balanced with the need to have the community large enough to provide sufficient cases and a sufficient range of patterns in the social environment. Questions may be raised [p. 132] concerning what is meant by “sufficient” and answering them would be one of the early steps in the research itself.

Community Size

In choosing a small community, it is realized that certain things are sacrificed. We do not seem to tackle the core problems of human beings in large urban areas, for example. We seem to be working in a backwater that is out of the stream of life where the most important and pressing problems are.

The answer to this is that it is advisable to profit by the general historic experience of science that you frequently fail to make progress by attacking the most crucial problems in a head-on fashion. In biology it has been found most profitable to approach problems where they can best be studied, where they present evident contrasts, where the dynamics are not too complex and fast moving. When the relatively simple is understood one can then move on to the more complex with a better chance of understanding and being able to devise critical experiments.

Let me say here simply that I see no conflict between the extensive and intensive research approach but, like Dr. Faris, ² regard them as the wrench and the screw driver. I do believe we have to crystallize our concepts in a well-understood, limited problem area and then test validity with extensive research oriented by the intensive. At the moment it looks as if a rural or semi-rural region containing both turmoil and stability in its social and cultural systems would be the best choice.

The Research Problem

In a sentence, the research problem is to analyze a community in order to determine the high and low areas of social-psychological stress and then to determine the distribution of mental disease in these contrasting areas.

Outline of a Research Plan

The first step is a careful descriptive study of the main features of social organization and cultural patterning in the community followed by detection and assessment of various kinds of stress in this context. Stress items would include such matters as broken homes, confused values, changes in way of life forced by technical innovations, unrealistic expectations, fear of the future and other factors of the sort suggested in the tentative hypotheses offered on page 128 [first list under ‘General Aims’] in connection with the general aims. In evaluating the nature and extent of these stress factors, opinion surveys would be used in order to give more definition and precision to the theories derived from the descriptive study and there would also be a compilation and analysis of relevant documentary sources of sociological facts. This might include some content analysis of the press and magazines.

When all the usable data on stress and its absence has been assembled, it will be analyzed to show which social patterns or [p. 133] cultural configurations are in the community most loaded with stress and which least loaded. The areas in between will for the time being be dropped from consideration.

This work will not be easy, but preliminary discussion with statisticians and sociologists leads to the expectation that the problems involved can be solved.

The next step will be the determination of the actual cases of neuroses and psychoses in the community and how they are distributed. One of the principal instruments to this end would be a mental hygiene team composed of a psychiatrist, two clinical psychologists, and a psychiatric social worker. The team would get cases referred from all over the communities under study by local doctors, teachers, welfare workers, the courts, and related sources. The members of the team, at the time they were receiving and working up the cases would not know the findings with regard to high and low stress areas. Eventually, however, their case material would be analyzed to see how well it matched the theoretical expectation.

We must recognize that the case finding might not be complete. It is possible that the mental hygiene team would get only selected cases and that the basis of selection might be such that a consistent bias would be introduced which endangered the validity of conclusions such, for example, as missing all cases in upper-class groups because they are not referred. It is therefore proposed that a psychological test, sensitive to personality disorder, be given to a random sample of the total population in each community under study. This would, of course, include the high and low stress areas. Then the results of the mental hygiene team findings and the psychological testing could be compared with each other in the light of the theoretical expectations based on the stress areas.

The steps thus far should result in some knowledge regarding the distribution of psychiatric disorders in relation to the social environment of the community. Further work would have to be guided by how the results confirmed, modified, or refuted theoretical expectation. However, it is almost certain that in any [p. 134] event there will be need for qualitative detailed data on the interaction of the individual and the social environment. We shall want to know something of life stories and of the ways individuals handle the social and psychological problems with which they are confronted. The research in the first stages will have provided this on the pathological cases through the work of the mental hygiene team, but there will be no such material on normals.

It is therefore proposed that 200 non-pathological individuals be studied by a standardized procedure which will be identical in all essentials with that used by the mental hygiene team. Furthermore, in order to secure as wide a range and as contrasting cases as possible for the purposes of provoking insight as mentioned yesterday by Dr. Aycock, ³ it is planned to select 100 individuals from low-stress environment and 100 from high-stress environment. Within this framework the individuals would be matched for age and sex with the pathological cases and then selected by random methods. The number 200 is in a sense arbitrary, but it is thought to be about the largest number that can be managed within the time and personnel resources that are likely to be available. It is estimated very roughly that this will be somewhere between a third and a half of the number of cases processed by the mental hygiene team.

In addition to providing controls to add to the detailed picture of the interaction of the abnormal person and the social environment, these 200 studies could serve as one more check on the distribution of disorders in terms of high and low stress. The numbers are small, of course, and the reliability of findings in this regard would have to be carefully evaluated.

Comparisons of the normal and pathological cases would lead to some tentative conclusions regarding differences in the personalities, social relationships, and experiences of the two sets of people, but would leave unanswered questions regarding prevalence and how far one could go in generalizing on the basis of 200 cases. For this reason, it is proposed that as a final step further surveys and psychological testing of large samples of the [p. 135] total population of the community be carried out. These will be pin-pointed to answer questions regarding prevalence of factors discovered in the analysis of the normal and pathological studies.

Out of all of this it is hoped that there will come some substantial data on the relationship between social environment and psychiatric disorders in these particular communities at the time. Although personality studies have been made in the past of normal individuals, there do not appear to have been any such studies carried out in the context of a community that was thoroughly known in social science terms and with an adequate work-up of the pathological cases occurring in the same place at the same time. It is anticipated that these data will have bearing on general concepts regarding the cause of mental disease, the sources of good mental health, and the theories of personality, culture, and group dynamics, as noted on page 129 [see Values of Concentrating Studies in One Community].