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BELIEF CORRELATES OF PSYCHIATRISTS

IN TWO SELECTED SETTINGS

BY

Kenneth Michael WOjcik

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Sociology
1972

ACKNCWLEDGMEN TS

The author gratefully acknowledges the help and assistance
of Dr. Peter Manning, whose critical insight was vital to this
thesis. The advice of Dr. Philip Marcus was also greatly

appreciated.

ii

TABLE OF CONTENTS
Page
mmmLst ......OOOOOOO..........OOOOOOOOOOOOOOOOO ii

LIST OF TABLES 0.0.0....0............OOOOOOOOOO000...... iv

INTRODUCTION ........................................... 1
DISEASE IDEOLOGY ....................................... 10
METHOD ................................................. 16
HYPOTHESIS ............................................. 21
RESULTS ................................................ 22
DISCUSSION ............................................. 27
CONCLUSION ............................................. 32

REFERENCES 0.000000...O.............OOOOOOOOOOOOOO...... 35

APPMIX A O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O C O O 39
APPme B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 40
APPMIX C O O O O O O O O O O O O O O O O O C O O O O O O O O O O O O O O O O O O O O O O O C O O C 42

APPEWIXD.........OOO0.0.0.000.........OOOOOOOOOOOOOOO' 46

iii

Table
1.

LIST OF TABLES

H scores for private and public along

ten tenets of the disease ideology
for a hypothetical case of anxiety ............

scores for private and public

psychiatrists along ten tenets

of the disease ideology for a

hypothetical case of depression ...............

scores for private and public
psychiatrist along ten tenets
of the tenets of the disease
ideology for a hypothetical

case of personality disorder ..................

iv

Page

23

24

25

INTRODUCT ION

This study concerns itself with the institution of psychiatry
in state mental hospitals and its supporting disease ideology.
Psychiatry as an institution is an organized prescribed system
of differentiated activities set up for the resolution of problems in
interpersonal relationships, intrapsychic dynamics, and social role
performance. Psychiatry is differentiated into specialized roles
(e.g. public and private) with complementary beliefs, attitudes and
values. As a speciality of medicine psychiatry has a mandate frOm
society to deal with problems of personality (Hughes 1958). Although
psychiatry holds this primary mandate, it has a very tenous claim
to exclusive competence and it receives competition from occupations
outside medicine (e.g. clinical psychology and counseling) and from
'within medicine. Also public recognition of competence if
prOblematical due to the nature of the problems, i.e. they are
part of everyday living,and the uncertain evidence of success

or cure of these problems (Wilensky 1964).

This introduction will attempt to delineate the general nature
of an ideology in a profession and then go on to examine ideology
in psychiatry with emphasis on the effect that institutional structure
has in a professional belief system. Another major consideration
will be the particular nature of psychiatry as a scientific

profession and the resultant role that an ideology holds in it.

Shils (1968) characterizes an ideology broadly as being
highly systematized or integrated around a few pre—eminent values
'with a high degree of explicitness over a.very'wide range of
objectives with which it deals. There is a consensus and a
commitment to it by its adherents with a closure to novel elements
and variations. Armor and Klerman (1968) delineate the unique
nature of a professional ideology positing it as a coherent system
of both existential and evaluative ideas. It is a series of
ideas Where eadh idea gains its support primarily by the virtue
of the other ideas in the system. The existential ideas for
a profession are those embodied in a codified knowledge'base.

They contain the particular judgement of What is correct and

What is not. Evaluative ideas are statements of what ought to

be for the profession. They correspond to the general goals such
as a code of ethics whidh are based on normative prescriptions
outside the formal knowledge base. It must be emphasized that
there is no clear dichotomy between evaluative and existential
ideas in a professional ideology. Also in a profession another
kind of evaluative idea is possible Where the codified.knowledge
base is incomplete or ambigous about means to attain a professional
goal, then the means chosen can have an evaluative basis. Finally,
as least some sub-group of the profession as a whole must identify
'with the ideology. It is importnat to note that this identification

may take place for only a small group While the majority will

maintain an eclectic position.

Ruesch and Bateson (1968) present psychiatry in America
today as a cumulative body of knowledge Which represents five
basic roots: psychoanalysis, psychobiology, experimental and
social psychology, state hospital psychiatry and medicine. From
these roots they posit five variables Which govern psychiatric
thinking, structurally organic determinats (e.g. heredity),
animalistic forces (e.g. instincts, drives), humanistic features
(e.g. emotions, abilities), effector determinants (e.g. emotions,
abilities), environmental determinants (e.g. social factors).
Psychiatrist have been said to maxmize one or more of these
variables in their conception of the etiology and the treatment
of mental illness. _Thus in modern psychiatry because of the
unresolved issues in the etiology of mental illness and the
resulting efficacy of treatments (psychotherapy, somatic, etc.)
the codified knowledge'base is amgibous. This allows a strong
belief in one treatment for all illnesses to be interpeted as
evaluative. It also allows opposing positions to be taken on
etiology, treatment and the resulting relationship between the
psychiatrist and the patient. American psychiatry serves then
as an example of a profession with conflicting beliefs.

A number of studies have investigated psychiatric attitudes
towards treatment and etiology. Hollingshead and Redlich (1958)
Characterized psychiatrists broadly as either directive—organic

or analytic-psychological. In their study of mostly private

practitioners the former type saw mental illness largley the
result of chemical and biological factors and offered a direct

and explicit explanation of What‘was wrong'with the patient's
behavior and What the proper behavior Shoudl be While the latter
type viewed mental illness as stemming from psychodynamic
processes developed in childhood and they offered psychotherapy
and psychoanalysis. Sharaf and Levenson (1957), concerned with
the mental hospital environment studied the orientations presented
in the hospital setting among psychiatric residents, find both
psychotherapeutic and sociotherapeutic orientations. The former
‘was similiar to the analytic psychological stance found in the
Hollingshead and Redlich study and the latter was seen as an
outgrowth of the hospital setting Which emphasized the use

of the hopsital environment as a device for therapy. The
sociotherapeutic orientation also posited mental illness as

the result of environmental and situational factors particularily
those that were recent. These factors were seen as most important
and thus it was the total environment that'was manipulated to

cure the disease.

Ehrlich and Sabshin (1964) working'with data from both
private and public mental hospitals, postulated these orientations,
somato.therapeutic, psychotherapeutic, and sociotherapeutic, as
three separate ideologies. Armor and.Klerman (1968) accepted the
postulate that these three orientations were distinct ideologies.
Using data from psychiatrists at fifteen hospitals both public

and private they characterized the psychiatrists as somatotherapeutic,

psychotherpaeutic and sociotherapeutic. The somatotherapeutic
ideology focuses upon.various somatic treatments, such as drugs
or electric convulsive therapy. (Mental illness is seen as a
reflection of organic diseases of the brain and disturbed
behavior is determined by altered brain functioning. The most
effective treatments are those that effect the physiological.
functioning of the patient. The psychotherapeutic ideology
empashizes psychotherapy including psychoanalysis as the most
effective treatment. It holds mental illness as resulting
primarily from intrappsychic forces that are determined to a
great extent by early childhhod experiences. The sociotherapeutic
ideology emphasizes multiple interpersonal and social situational
encounters occurring in the patient's treatment setting. Here
the manipulation of various environments, the group, the hospital
or the community is used for therapeutic purposes. There is the
belief that mental illness is caused by social and environmental
factors usually of recent occurrence. They found that‘both the
psychotherapeutic and socatotherapeutic ideologies were the most
deve10ped and each stressed that this was the best or only therapy
for mental patients. The sociotherapeutic orientation lacked
both content and commitment, it'was less developed and simply was
an assertion that social factors are important in treatment. It
approved of other therapies and saw forces other than environmental
as important in the etiology of mental illness. Sociotherapy'was
concluded to be too new to have developed a complete ideological
status.

It is necessary to consider also the growing literature on.the
effect of institutional structure on the psychiatrist and his
ideology, as a practitioner he exerts himself in particular social
settings. Institutional structure is determined by the particular
organization (e.g. state of private mental hospital) that the
psychiatrist is affiliated with and that he works in. Scott (1966)
posits the professional model as one where a free agent, the
professional, contracts a service for his client. The professional's
first loyalty is to his client. Their theories and practices
are formulated for their clients. The professional is thus
characterized by antonomous expertise and a service to client
ideal. This model of a free professional does not though meet the
realties of the professional in the organization. Here there
are basic areas of conflict between the professional and the
organization that must be resolved. Scott notes four such areas,
resistanbeto bureacratic rules, rejection of'bureacratic standards,
resistance to bureacratic supervision, and conditional loyalty
to the organization. These areas are then subject to processes
of negotiation, manipulation, and various other exchanges between
professional and organization that facilitate the maintance of this
particular relationship. Professional ideology is significantly
involved in this total relational mix of professional and organizational

structure.

Szasz (1961) contends that an ideology of illness serves the
psychiatrist in the state mental hospital as a rationalization
and defense for the involuntary commitment of mental patients.

By presenting mental disorders as disease processes the psychiatrist

expresses an ideology which is in harmony with the structure

of state mental hospital.

subsequently, Szasz (1963) views the goal of psychiatry as
helping individual people to gain more power over their lives so
that they could best achieve their goals. When psychiatry
exists as a social institution serving as a regulator for one
of the functional prerequisites of society, it seeks to insure
the status quo and promote the prevailing interest of society
and enhance its own power and status. Psychiatry, than, no
longer places the values of the individual first for the values
of the group are preeminent. He thus contends that the social
setting that the psychiatrist is in determines his relationship
with the patient, the particular action he takes and the aim.of

his diagnosis.

In particular, the bureaucratic setting forces psychiatry
to change so radically that it can no longer be considered the
profession of psychiatry because the professional's rights and
duties have been redefined by the organization. Iniihe state
mental hospital the psychiatrist is the employ of the state, therefore,
he functions as an agent for the state. The patient is segregated
from society in the institution usually as a result of conflict
'with social norms. The psychiatrist must then justify both this
retention and the subsequent release of the patient. But in

private practice the psychiatrist may engage in various forms

of therapy and he justifies this action byczoncern for helping
the patient. While in the mental health clinic the psychiatrist
is an employee of the clinic but his alleginace is divided
between the patient and the demands of the community; Here he
must justify the acceptance or rejection of a particular

patient and he engages in various types of psychiatric treatment
in accord with the justification for treatment. Thug the methods
and the purposes of the psychiatrist differ in these three

social settings.

Strauss, et a1 (1964) in their study of two psychiatric
hospitals, found that ideologies are associated with institutional
locales in that the predominent ideology varies amon'g psychiatric
institutions, and particular institutions can be characterized
as representing particular ideologies. The researchers also
discovered that ideological convictions generated their own
morality. The behavior of the professionals was'highly charged
morally. Treatment procedures was such an area Where morality
'was at issue. The psychotherapeutically oriented peOple viewed
shock therapy as at worst barbarous or midievil and at best
crudely expedient. Somaticists frequently accused psychotherapists
of eXhausting families' financial resources'without alleviating
patients conditions. Psychotherapists criticized somaticists for
turning patients into zombies with drugs who could not.be helped
with their basic problems. Somaticists felt that pschotherapists
were unnecessarily cruel in not diminishing patients' suffering.
‘What the ideology prescribed then defined both improper practice

and the framework for judging the efficacy of other treatments.

......

It is of course natural for an ideology to determine morality
for it is a total pervasive belief system. Thus the institution
serves the psychiatrist as further evidence to the efficacy

of his own orientation because it is in agreement with'his

ideology.

Finally, there is the example of military psychiatry
where bureacratization overwhelms and completely regulates the
psychiatrist. Daniels (1969) in an investigation of psychiatry
in the military states that ambiguities in psychiatric theory
allow the justification for a particular relationShip'between
the psychiatrist;and the patient. Here a particular ideology
which places the aims of the organization.as primary justifies
a.psychiatrist's actions even though they may be contrary to
other norms in the profession. In the case of the military
a client is not the first consideration of the psychiatrist. His
orientation is to the organization and his ideology serves as
a generator for the morality of his particular methods. His
professional goals, standards. etc., are those of the military.
The psychiatrist makes his psychiatry adjust to fit the military
context. Rose (1958) delineates this adjustment procedure in
the classification of neuropsychiatric cases during WOrld‘War II
as one where administrative criteria played a significant a role
as official psychiatric criteria. Decisions were thus directed

by the needs of the organization.

10

To recapitulate, psychiatry has been presented as a profession
that adjusts itself to the organization context that it is part
of. Ideology plays a major role in this adjustment by legitmating
the operations of the psychiatrists in the social settings. The
existence of seemingly conflicting norms in psychiatric practice,
treatment, and doctor-patient relationShip is the result of
differing ideologies which grOW'out of the ambiguities in
psychiatric theory. Specific orientations in psychiatric
practice have been noted, but our concern nOW’Will be with the
disease ideology. The disease model can be seen as a conceptual
scheme that is applied to behavior. Its roots are medicine,

psychobiology, and state hospital psychiatry.

QI§EASE-IPEQEQG¥

Szasz (1961) contends that the development of modern public
psychiatry has been a function of the development and expansion
of the concept of illness. It has become an elastic category
capable of including anything a psychiatrist chooses to place
in it. He notes that the precipatating factors that made this
possible are one, the extension of the concept of illness from
a disorder of the body per se to what appears as a disorder of
the body but is really a so—called mental disorder, and two, the
recognition of the sick role as a sufficient criterion of the
existence of an illness. The first factor is the result of
the work.of Freud.who reclassified malingers as patients
suffering from the disease, hysteria. This disease had no
physiological cause but manifested itself in bodily symptoms.
The second factor is the result of society imparting a social
status upon an individual by its societal agent (i.e. the
psychiatrist) for engaging in abnormal behavior. Psychiatry
'was able to impute illness to a.whole range of individuals
Who exhibited such.behavior'by using their societal mandate
to equivocate a social status, sick role, as a sufficient

criterion of illness.

Scheff and Sundstrom (1970) point out that in a disease
framework.for mental disorder there is a cause, course, lesion,
symptom pattern, and treatment choice. They further note
that an unstated but important premise of this framework is
the stability of symptomatic behavior overtime. Black (1971)

12

refutes this unstated premise by detailing the nature of the
disease model as allowing for self—terminating disorders. There
are disease states that terminate naturally without treatment.

He suggests that it is difficult to specify the disease model

as widely conceived by practitioners. There have though been

some attempts to delineate both the conceptions of disease and
some basic tenets for these conceptions. Fabrega (1971) posits
three logically distinct conceptions of disease, biologistic,
behaviorial and phenomenological. A'behaviorial view sees
behavior changes as consequences of biological processes. In
this conception of disease, types of diseases are categorized by
the way an individual's responses to demands are affected.

There are then indications or symptons for these various

disease types. Psychiatric disorders conceived within a
behaviorial disease framework are conceptualized metaphorically
as biologistic disease processes. Taber, et a1 (1969), present
four basic components included in the disease model significant
to medical practice. They are, nosology, pathology, etiology

and treatment. Each of these four components can be transposed
to the behavior disease model so that mental disorders are
conceived in medical disease terms. Nosology is a classifactory
scheme for illness. Each classification is mutually exclusive
and the disease is generally considered as being either present
or absent. Pathology is the underlying process that occurs in
the organism that corresponds to the symptoms that are observable.
Etiology is the belief in a pernicious agent as the causal factor
in the disease. Therapy holds that treatment will favorably effect.

13

the condition. Mental disorders conceived'within these
components emphasize behavior as a consequence of underlying
pathology that follows a causal sequence and can be both
diagnosed and likely treated.

This Study devised ten tenets of the disasee ideology as
delineated by Taber, et a1, (1969) (Appendix A). These
tenets are both existential and evaluative. They relate
to the codified knowledge base regarding the components of
nosology, pathology, etiology, and treatment and they also
relate to evaluative normative prescriptions regarding responsibility
and the total effect of treatment on the individual. Tenet one,
qualitatively different states of disorder in the personality
exist and can be identified, is an element deduced from the
concept of nosology. Tenet two, an underlying condition can
be inferred from the observable symptons, is deduced from the
concept of pathology. Tenet three, the illness of process
persists'within the personality over some lenght of time is
another element from pathology. Tenet four, personality disorder
significantly reduces the responsibility of the individual
for his behavior, is an evaluative prescription that derives
from the concept of disease. Tenet five, the illness process
is the result of a pernicious agent and a particular causal
sequence, is an element that comes from the concept of etiology.
Tenet six, a single necessary and sufficient cause is’present
in personality disorders, is another element that is deduced
from the concept of etiology. Tenet seven, directed intervention

is effective in the correction of personality disability, is

-- ‘1‘!

14

an element derived from the concept of treatment. Tenet eight,
directed intervention with drugs is effective in the management

of personality disability, is an element derived from the concepts
of etiology and treatment. Tenet nine, treatment intervention

is not inimical to the organism and thus essential if there

is a possibility of illness, is an evaluative prescription of

the disease ideology. Finally tenet ten, effective treatment

is dependent on the motivation of the individual, is deduced

from.the concepts of etiology and treatment.

This study is concerned with these ten individual tenets
and the degree of consistency of high and low intragroup agreement
for public psychiatrists for the three hypothetical cases as
compared to the intragroup agreement of a group of private
psychiatrists. An ideological system has support in different
settings and the support for individual tenets may vary for any
psychiatrist in that setting. By comparing these two settings
we are able to determine patterns that may exist in either.
These will provide insights into both the content of the
ideology in either setting and into any evolutionary processes
that my be bringing about change in flat particular setting.

1.

2.

3.

7.

9.

10.

Ten Tenets Of Disease Ideology

Qualitatively different states of disorder in the personality
exist and can be identified. *

An underlying condition can.be inferred from the observable
symptons. **

The illness process persists within the personality over

some length of time. **

Personality disorder significantly reduces the responsibility
of the individual for his'behavior. ***

The illness process is the result of a pernicious agent

and a particular causal sequence. ****

A single necessary and sufficient cause is present in
personality disorders. ****

Directed intervention is effective in the correction of
personality disability. *****

Directed intervention'with drugs is effective in the
management of personality disability. ******

Treatment intervention is not inimicalt to the organism

and thus essential if there is a possibility of illness. ***
Effective treatment is dependent on the motivation of the
individual. ******

* ~— inferred from concept of nosology

** __ inferred from concept of pathology

*** —- an evaluative prescription for the ideology

**** .... inferred from concept of etiology

***** —— inferred from concept of treatment

****** —— inferred from concepts of etiology and treatment

CE

METHOD

The primary interest of this study was the differences
between private and public psychiatrists along the ten tenets
of the disease ideology. We drew a sample of each of these
papulations. It was assumed that private psychiatrists have
no ideological commitment to the disease model of mental
disorder. Although they may exhibit certain consistencies
with that model, their major concern is with each individual

patient .

The subjects consisted of seventy staff psychiatrists
at five state mental hospitals in Michigan at Pontiac, Northville,
Traverse City, Kalamazoo and Ypsilanti. Their names were
chosen from lists of staff psychiatrists at these hospitals
secured from the superintendents of each. Except at Kalamazoo,
where a list of ten psychiatrists was received, all staff
psychiatrists at each hospital received a questionnaire
(Appendix C). The ten psychiatrists at Kalamazoo were also
sent the questionnaire. A" control group of one hundred
psychiatrists engaged in private practice in the Detroit Metropolatian
area was randomly chosen from a 1970 listing of the active
members of the Michigan district branch of the American
Psychiatric Association. The questionnaire was mailed twice.
Realizing that psychiatrists may regard a mailed questionnaire
as both a threat to their institutional domain and an inadequate
means of obtaining information (Deutscher 1956) a different

questionnaire (Appendix D) was mailed to the five superintendents

‘Ifi

17

of the state mental hospital that'were surveyed. This questionnaire
allowed for both an administrative ViGW'Of Operational procedures
and a check on the congruence between staff and administrative
levels. Consequently, it also served as a check on the validity

of the responses of the staff psychiatrists.

The questionnaire (Appendix C) mailed to the private and
public psychiatrists consisted of three hypothetical cases and
a series of eleven questions for each case. A hypothetical case
of anxiety, of depression, and of a personality disorder were
formulated from the symptoms usually associated with these
disorders as detailed in a psychiatric handbook.(Hofling 1968).
All the psychiatrists received the same three example cases.

Certain'behavior was reported for each ficitious case.

Ideally, Observation of the intake interview, questioning
of attending psychiatrists, and analyzing official records
would be tactics used to obtain data for this study. However,
since this was not possible, hypothetical cases were used. They
have been used quite regularily before in the determination
of mental health attitudes (Star 1961: Fletcher 1967: Fletcher 1968)
and‘have certain advantages. The fictious cases were structured
to isolate critical elements regarding illness and non—illness.
They thus stimulate decisionemaking for the respondent and produce
discrimination in responses by precisely detailing components
of the particular case. For our purposes fictious cases are
"neater" than real life because they are unencumbered with other

18

intervening variables.though these variables may sometimes be significant.

The series of questions following each case referred to
the following: (A) the psychiatric relevance of the behavior (2),
(B) What further aspects of the behavior would be important
to know’(2), (C) the direction that a professional relationship
would take (2), (D) What the developmental pattern might
have been (1), (E) the responsibility of the individual in
his situation (1), (F) What is therapeutically beneficial
and situation (1), and (G) what would be crisis and resolution
situations for the individuals (2). These questions were
designed to bring out the premises that the psychiatrist held
underlying'both his existential and evaluative conceptions
of particular disorder states. These particular examples,
anxiety, depression, and personality disorder, were chosen
to represent typical disorders.

The questionnaire (Appendix D) mailed to the hospital
superintendents dealt with certain changes that have been
reported as occuring in state mental hospitals (Folta and
schatzman 1968). These questions related to the following:
(A) the demise of the traditional form of the mental hospital,
(B) increases in research and training, (C)redirection of
treatment philosophy, and (E) the consequences of the changes

for mental patients.

19

The responses received from the questionnaire mailed to
public and private psychiatrists were analyzed for evidence of
an affirmation or negation of the ten tenets of the disease
model that were proposed (Appendix A). A three point scale was
used for each individual tenet, affirmation, negation, and
abscence of any information. The affirmation and negation
points are delineated in the code (Appendix B) for each tenet.
All responses for each case'were coded for the ten tenets.
Where there was no information for a particular tenet a
zero was recorded for the psychiatrists on it. Thus each
psychiatrist. on each reported case affirmed, negated, or
neglected all ten tenets of the disease ideology. The responses
received from the superintendents were not subjected to
an coding procedure'but were analyzed for'major themes and

trends.

The information received from the analysis was summarized
for each group, public and private, in percentage terms. Each
tenet for each of the three cases had a percentage score for
the three points on the scale for the public psychiatrists and
the private psychiatrists. From these percentages a nonmetric
measure of dispersion or variability was computed for each
tenet and each group on all the cases. This information variable,
H, indicates the amount of uncertainity or information expressed.
(Atteave 19597 Garner 1962). This“variable is calculated by means

of the formula:

20

The set of prObability values needed to compute this variable
were derived from the percentages computed from the responses
for a tenet along the three point scale. An elevated value of

H indicates that the responses on a tenet contain a great deal
of information, which can also be seen as great hetrogenity

in responses. A low'H reflects low uncertainity, which indicates
that the group‘has high agreement or homogenity and consensus on ~
that tenet. This measure allows us to compare the homogenity

of public psychiatrists along the ten tenthSOf the disease

model with the amount of homogenity of the private psychiatrists
along the ten tenets. We have then a means of determining
whether an ideological commitment to the disease model exists
among psychiatrists in state mental hospitals. There H scores
would'be significantly lower on almost all of the tenets in

relation to the H scores of the private psychiatrists.

1.

HXEQITEE§IS

Public state hospital psychiatry can be characterized
as commited to a disease ideology of mental disorder.
a. intragroup agreement for staff psychiatrists
of state mental hospitals'will be greater
than intragroup agreement for a control

group of private psychiatrists.

.21

RESQLTS

The major hypothesis to be tested: (1) that psychiatrists
practicing in state mental hospitals have greater commitment
to a disease ideology than do psychiatrists engaged in private
practice. Private psychiatrist are assumed to have no ideological

commitment to the disease model of mental disorders.

Thirteen responses were received from.the public psychiatrists
and twelve responses from the private psychiatrists, response
rates of nineteen percent and twelve percent respectively. All
respondents were male with the exception of one female in the
public sector. All respondents fell within the thirty to forty—

five age grouping.

Fer the hypothetical case of anxiety the public psychiatrists
had lower H scores in eight out of the ten tenet-8;; but in most
cases these were small. The chi-square test did not produce a
significant value. This suggests only a.very mild tendency
for public psychiatrists to have'higher intragroqaagreement
than private forahypothetical case of anxiety.

an

23

Table 1 —- H scores for private and public psychiatrists
along ten tenets of the disease ideology for a

hypothetical case of anxiety.

TENET # PRIVATE PUBLIC
1. 1.04 .88
2. .44 1.02
3. 1.04 .72
4. .82 .88.
5. ,69 :40
6. 1.04 .96
7. .92 .82
8. .98 .82
9. .99 .96

10. .92 .70
I! = 12 ‘N = 13

For the fictious case of depression the public psychiatrists
again have lower H scores in eight out of the ten tenetsg. Again
these differences are very small and the chi-square value was not
significant. So this is then only a slight tendency for public
psychiatrists to have high intragrgnpaegneementhon this second

example case.

\[ll'lllll'l [fl [fl .{f I]

 

 

24

Table 2 —— H scores for private and public psychiatrists along

ten tenets of the disease ideology for a.hypothetical
case of W.

TENET # PRIVATE PUBLIC
l. .80 1.04
2. .80 .58
3. .90 .69
4. 1.02 .65
5. .68 .58
6. 1.08 .58
7. 1.03 .98
8. .70 .47
9. .68 .69

10. .80 .69
N = 12 N = 13

For the hypothetical case of Egrsonglity disorder the
public psychiatrists'haye lower'H scores on six of the ten

tenets. These differences too are all very small and the ‘
chi—square test did not produce a significant value. This
suggests almost no difference in intragroup agreement'between
public and private psychiatrists foraficitious case of

personality disorder.

25

Table 3 —— H scores for private and public psychiatrists along
ten tenets of the disease ideology for a hypothetical

case of personality disorder.

TENET # PBIVATE PUBLIC
1. .66 .70
2. 1.04 .82
3. .58 .58
4. .99 .69
5. .69 .66
6. .99 1.04
7. 1.04 1.04
8. .92 .69
9. 1.04 .69

10. .82 .82
N812 N=13

It is important also to note the various patterns for
each group that may have emerged along the ten tenets for the
three cases. For the private psychiatrists low'H scores were
found for tenets two and five on case one, tenet five on case two,
and tenets one, three and five on case three. Only tenet five
is consistently low for the private group. Fer the public group
only tenet five is low for the first case, tenets two, five, six
and eight for the second case, and tenet five for the third case.
Again only tenet five is consistently lOW'fOr the three cases for

the public group. Thus high intragroup agreement for the entire

26

sample is found only in tenet five which relates to the concept of
etiology, positing a causal sequence and a particular agent in
a.mental disorder. Although this is a tenet of the disease
ideology, the belief in a causal sequence and agent is a
significant factor in all Western thought. There then seems

to be no other discernible pattern of high intragroup agreement
among the two groups.

DISCUSSION

These results suggest that public psychiatry as practiced
in state mental hospitals operates under no greater commitment
to a disease ideology than does private psychiatry as practiced
in an entrepreneutrial setting. Further, this limited evidence
refutes the past characterization (Szasz 1961, 1963) of public
psychiatry as an institution that secures and justifies its position
in and to society by means of a disease metaphor applied to the
personality system. Thus the evidence suggests that the modern
mental hospital has to some extent moved away from an ideological
stance of disease implying, also, changes in both operations

and techniques.

Let us now reiterate that the literature points out that
ideology in psychiatry has changed according to the organizational
context that it is in. Ideology in the occupation has been
directly affected by social structure. Thus if ideology
in the state mental hospital has indeed changed it is the social
structure of the mental health system that we will look at
to explain that change and the answers received from the state
hospital superintendents will be used as insights into the

nature of this social structure.

Most significantly the recent period has seen the emergence
of the community mental health movement. It is offered that
this movement has affected public psychiatry vis—aavis its role

in society and thur altered its psychiatric orientation. This

27

28

neW'mental.health organization is characterized as One
consisting of a team.approach with both professional and non—
professional community members on the team.(Berlin 1969).
There is an emphasis in these mental health centers on
providing many services ranging from crisis care to education
and prevention (Freeman and Gertner 1969). These centers
then are developing new ideas and techniques to handle mental
health prOblems. These new ideas and techniques then have an
effect on the rest of the profession including state mental
hospital psychiatry. So there is a direct effect from
innovations changing the stance of the mental hospital

ideology and operational philosophy.

On another level, the community mental health movement
is changing the organizational structure of the state mental
hospital by redirecting the role of the mental hospital in
the mental health network. Folta and schatzman (1968)contend
that the mental hospital no longer exists in its traditional
(i.e. long term.custodial care) form.but increasingly serves
as a back-up system to city and community mental health efforts.
The state mental health hospital‘has also become more involved
in research and professional training. So there is a movement
towards a rational system of community and state services where
a commitment is made to reduce overlap in functions and
provide an integrated system of mental health services to
the public. The state mental hospital has redirected its efforts
from its previous basic goal of long term custodial care of major

mental illnesses (Strauss and sabShin 1961) to more diversified

29

services and operations.

Finally, there is the further contention'by Folta and
Schatzman (1968) that the community mental'health.movement in
accordance with heightened.political consciousness in civil
rights and desire for autonomy in decision making‘has affected
the operational philosophy of the state mental hospital. The
community mental health organization manifests this community
activity and awareness in its operational philosophy zand
its techniques. These then effect both the professionaand
the public system of psychiatric service. Specifically, there
is an emphasis on personal—social determinism rather than
personal—historical determinism with resulting stress on
client choice and responsibility. This then leads to a focus
on the individuals actions, current situations, capabilities,
etc. rather than his history, character, etc.—doing rather
than being. These psychiatric concerns are not'within a
disease ideology of personality disorder‘but rather are part

of some different framework.

The questionnaire mailed to the superintendents of state
mental hospital attempted to get a reading of the extent
to which their hospitals has indeed been effected by the
community mental health movement. The picture that can‘be
drawn from their responses reflects the recurrent themes

from all the respondents.

Regarding the state mental hospitals traditional custodial

30

role all responses indicated movement away from this role.
The extent to which their own hospital'was removed from the
role varied. But even the response that noted the least change
from the traditional form remarked, "significant changes

are taking place and state mental'hospitals are becoming more
and more gctive psychiatric treatment centers with increasing
involvement in community mental health programs." All
respondents noted that the state mental hospital is becoming
increasingly involved in research and professional training.
Only the lack of funds has limited these Operations and all
note that the state mental hospital in the future will most
likely become more a center of research and professional

training.

As to the effect of heightened political consciousness on
operational philosophy, all respondents noted that these
activities have certainly influenced the operation of tht:
hospital. One respondent commented, "the state hospital is
part of the community and culture and cannot be separated
from the present'wave or current of change." As might be expected
the operational philosophy of personal-social determinism,
client responsibility,current actions, etc., is viewed by
all as receiving increasing attention in their hospitals. These
foci are seen as complementary to the current changes in
community awareness. One respondent explained, "increased
concern about civil and constitutional rights has been most
helpful in breaking down traditional outmoded state hospital practices."

31

The most recurrent theme from the superintendents is
that the state mental hospital is in a stage of transition.
They are certainly aware of where they have come from.somewhat
uncertain of the direction they are to take. One respondent
related specificfldirections that his hospital'was moving
toward. He said, “we see our own function as that of a
regional mental health center, serving as the hub for a cluster
of community mental health centers and offering training,
research and rehabilitative programs." Regarding operational
philosophy this same respondent noted, "our ideal is the model
of Maxwell Jones' therapeutic community in'which patients
and attendants are all seen as co-equal partners of the
professional members of the team. We increasingly deemphasize
diagnostic labels and past history and focus on an individual
treatment plan for each patient which the team constantly
reviews and and revises." Although none of the other superintendents
were as precise as these statements their answers suggested

at least some movement in these directions.

CONCLUSION

It is offered, as suggested by the limited empirical
evidence gathered by this study on both the staff and
superintendent levels, that psychiatry as practiced in the
state mental hospital can no longer be characterized as
operating within a disease framework for mental disorders.
Folta and Schatzman (1968) contend that public psychiatry
now'has no'acceptable ideology which is related to the new
institutional operations and Vocabulary. As the disease
medical model has justified retention of the mentally ill
so to will this new ideology, support and justify the techniques
and goals of public psychiatry. This new framework is being
developed and modified by the organizational structure emerging
in mental health on both the community and state level,
technological advances in chemoterapy (e.g. anti-psychotic‘:
drugs) and social change in the awareness and concern of
individual citizens regarding mental health. Neither the
content or structure of this emerging ideology, are clearly
delineated. ‘What is clear is that the changing patterns of
public psychiatry have begun to incorporate conceptions of
quality humane treatment, individual responsibility and choice,
and uniqueness and complexity of each individual's problem.
Certainly, full realization in all public psychiatric sectors
of these conceptions has not been achieved but if the disease
ideology has begun to fall then a significant impediment to

such realizations is being removed.

32

33

On a professional level these tentative results have some
important implications for psychiatry in the future. First,
the results suggests a breakdown of the relationship between
psychiatry and medicine. The psychiatrist in the state
mental hospital seems to no longer embody in his work a
traditiOnal medical model, the process of disease. Ben—David
and Collins (1969) note that the growth of a new paradiagm
occurs when and where persons‘become interested in the new
ideas not only as intellectual content but as a potential
means for establiShing a new'intellectual identity. Psychiatry
then as a profession serving the public sector may now'be
seeking out a new societal mandate that will replace the
present mandate that it'hasig.medical speciality. Psychiatry
might then move out of medicine and a new'merging of the
social sciences with psychiatry may take place producing
professionals with no medical identities. Such changes now
in developmental stages would be nurtured by the increase of
awareness in the occupational responsibility that public
psychiatry has in a changing society. These responsibilities
are, of course, manifested to public psychiatry by the
allocation of financial resources for operations. As resources
become increasingly allocated to community mental health
projects there would seem greater liklihood of a break between

medicine and psychiatry.

34

It is offered that organizational structure in the
future will increasingly influence the ideological system
that public psychiatry will use to justify its methods and
techniques. Further, the nature of the profession itself
'will'be progressively influenced by the context of the social
structure as public psychiatry seeks and maintains a neW'
mandate that is not subsumed from.medicine. Some'broad
prospects for this neW'profession are delineated by Levinson and
Klerman (1967) and central to these new role tasks for
the psychiatrist is an awareness of the social system of the
organization that he is a part of and its societal contxt.
Most basically, psychiatry is moving toward a more reflexive

and adaptive stance vis—aevis its society.

REFERENCES

Armor, David J. and Gerald L. Klerman
1968 "Psychiatric treatment orientations and professional
ideology." Journal of Health and Social Behavior
9 (September): 243 — 255.
Attneave, F.
1959 Applications of Information Theory to Psychology.
New York: Holt.
Ben—David, Joseph and.Randall Collins
1969 "Social factors in the origin of a new science:
The case of Psychology" American Sociological Review
31 (August): 451 - 465.
Berlin, Irving H.
1969 ”Resistance to change in mental health professionals."
American Journal of Orthopsychiatry 39 (January): 109 - 115.
Black, Stephen
1971 "Deviant behavior over time: A comment." Journal
of Health and Social Behavior 12 (March): 81 — 83.
Daniels, Arlene K.
1969 ”The captive professional: Bureacratic limitations
in the Practice of Military Psychiatry." JOurnal of
Health and Social Behavior 10 (December): 255 — 265.
Deutscher, Irwin
1956 "Psyeicians' reactions to mailed questionnaires:
A study in resistenialism." Public Opinion Quarterly
20 (Fall): 599 — 604.

25'

36

Ehrlich, D. and M. Sabshin
1964 Chapter 4 in Strauss, et a1, Psychiatric Ideologies
and Institutions. New'York: Free Press.
Fabrega. Horacio Jr.
1971 "Conceptual equivalence in cross—cultural medical
studies" Paper presented in.Cross—Cultural Symposium.
Indiana University.
Fletcher, c. Richard
1967 "Assigning responsibility to the deviant: A factor
in psychiatric referrals by the general public."
Journal of Health and Social Behavior 8 (September):
185 — 197.
1968 "Social class variations in psychiatric referral of
'withdrawn and aggressive case descriptions." Social
PrOblems 16 (Fall): 227 — 241.
Folta, Jeanette and Leonard Schatzman
1968 “Trends in public urban psychiatry in the United States."
Social Problems 16 (Summer): 60 — 72.
Freeman, Howard and Rosalind Gertner
1969 "The changing posture of the mental health consortium."
American Journal of Orthopsychiatry. 39 (January): 116 — 124.
Garner,‘W. R.
1962 Uncertainity and Structure as Psychological Concepts.
New York: Wiley.
Hollingshead, A.B. and F.C. Redlich

1958 Social Class and Mental Illness. New York: ‘Wiley.

37

Hofling, Charles K.
1968 Textbook of Psychiatry for Medical Practice.
Philadelphia: J.B. Lippincott.
Hughes, Eyerett C.
1958 .Men and Their Work Glencoe: The Free Press.
Levinson, Daviel J. and Gerald L. Klerman
1961 "The Clinician-Executive." Psychiatry 5 (February): 3—15.
Rose, Arnold M.

1958 ”Administrative and official criteria," Administrative

Science Quarterly 3 (March): 195—194.
Ruesch, Jurgen and Gregory Bateson

1968 Communication: The Social Matrix of Psychiatry.

New“York: ‘w.w. Norton Co.
scheff, Thomas J and Eric Sundstrom

1970 "The stability of deviant behavior over time:
A reassesment.“ Journal of Health and Social
Behavior 11 (MarCh): 37—43.

Scott, we.

1966 "Professionals in bureacracies: Areas of Conflict."
in.H.‘Vollmer and D.L. Mills (eds) Professionalization,
pp. 265—275. New'Jersey: Prenticeéflall Inc.

Sharaf, Myron R. and D.J. Levinson

1957 "Patterns of ideology and role definition among
psychiatric residents. In Greenbelt, et al, (eds)

The Patient and the Mental Hospital. New'York: Free Press.
Shils, Edward
1968 "Ideologyt International Encyclopedia of Social Sciences.

Macmillan and Free Press.

38

Star, Shirley
1961 The Dilemnas of Mental Illness Citied in the
Joint Commission on Mental Illness and.Health.
Action for Mental Illness. New'York: Science Editions
Strauss, Anslem, et a1.
1964 Psychiatric Ideologies and Institions. New York:
Free Press.
Strauss, Anslem and Melvin sabshin
1961 "Large State mental'hospitals." Archieves of
General Psychiatry 5: 565-577
Szasz, Thomas S.
1961 The Myth oijental Illness. New'Eork: Hoeber
and,Harper.
1963 Law; Liberty and Psychiatry. New'York: .MacMillan Co.
Taber, Merlin, et al
1969 ”Disease ideology and.mental health research."
Social PrOblems 16 (Winter) 349—357.
Wilensky, Harold L.
1964 "The professionalization of everyone?" American
Journal of Sociology 70 (September): 137-158.

APPENDICES

I}..HEIIIIEEJIEE1§1E1{ [fl I‘ll. [[1 I' [1|
[E

APPENDIX A

Ten tenets of disease ideology.

1.

2.

7.

10.

Qualitatively different states of disorder in the personality
exist and can be identified.

An underlying condition can'be inferred from the cbservable
symptoms.

The illness process persists within the personality over some
length of time.

Personality disorder significantly reduces the responsibility
of the individual for‘his behavior.

The illness process is the result of a pernicious agent and a
particular causal sequence.

A single necessary and sufficient cause is present in personality
disorders.

Directed intervention is effective in the correction of
personality disability.

Directed intervention'with drugs is effective in the management
of personality disability.g

Treatment intervention is not inimicale to the organism and
thus essential if there is a possibility of illness.

Effective treatment is dependent on the motivation of the
individual.

39

APPENDIX B

Coding procedure for each tenet of the disease ideology.

1.

2.

The use of psychiatric categories affirm the tenet. Evidence

of the use of subjective intrapersonal affect and interpersonal
relationship disturbances negate the tenet.

An explanation that symptoms are manifestations of an underlying
disturbance of disorder process affirms the tenet. A focus

for the Observable symptoms as the substance of significant
concern negates the tenet.

An emphasis on past experiences as being most important affirms
the tenet. An emphasis on the most recent life situations and
present state of the individual negates the tenet.

A response that the individual has little or no control over
his actions affirm the tenet. A response that suggests that

the individual is still responsible to interact in relationships
in a.mature fashion negates the tenet.

A response that indicates particular causes in a particular
sequential fashion affirms.the tenet. A response that is
concerned'with the present life situation and disregards a
causal sequence negates the tenet.

There is an emphasis on a single sufficient cause with no

sense of interaction between causes affirms the tenet. An
emphasis on the interaction of particular causes negates the tenet.
Therapy directed at curing or resolving the disorder affirms the
tenet. Directed intervention has no value in resolving the
disorder but may provide insight into the prOblem allowing the
individual to knOW'himself negates the tenet. Also intervention

whose sole goal is support negates the tenet.

4O

9.

10.

41

Therapy such as drugs and tranquilizing agents recommended to
ease the individual in life situations and crisis encounters
affirms the tenet. 'Viewing management of life situations

as not a goal of psychiatry but these situations must'be
handled by individual'himself negates the tenet.

Emphasis on hospitalization, therapeutic mileus, etc. as
taken for granted in present analysis affirms the tenet.
Evidence that professional relationship exists in nonptreatment
or insight—type fashion'with patient on an equal level'with
doctor negates the tenet.

Emphasis on the motivation of the individual to get well
affirms the tenet. Emphasis on the patient's own ability to
handle life situations with no concern for his motivation for

treatment negates the tenet.

APPENDIX C

Questionnaire mailed to pUblic and private psychiatrists.

PHYSICIAN QUESTIONS
Instructions
1. This questionnaire should take twenty to thirty minutes.
2. ‘Write a brief answer for each question of each example case.

3. There are no right answers, we are interested in your
responses as a psychiatrist.

4. Please return the questionnaire in the self—addressed
envelope.

Exam 1e C e 1

Individual is a female, thirty years old. She expresses
sustained tension and being constantly on edge. She has difficulty
in sleeping. She reports being preoccupied with worry over mental
and physical conditions and complains of many minor aches and pains.
Her hquand complains of her chronic irritability, suspiciousness
regarding his activities When he is away from.her and her lack of
cooperation in his attempting to help her. The individual also
complains of headaches, shortness of breath, inability to concentrate
and Sharp twitches of pain in her chest. She reports a negative
attitude toward her doctor and her medical care complaining that he
is not listening to her and that She cannot talk to him. Finally,
she reports of a general unhappiness regarding herself and her life.
She faces the day uneasy and has no explanation for it. She cannot
pinpoint When it all started but it is recent and both the intensity

and extensiveness of this uneasiness is increasing for her.

42

I .. t - -I I! .fllt .‘ll!\!ll! If...lll\f Il|§llII {fl (fl! I‘lll Ill (If. [[.[III [II [III .{I .Illll.

43

Questions

1. Is this reported behavior significant to you, as a
psychiatrist? If so in What way(s)?

2. Does this behavior signify to you a particular mode
of action of personal organization of this individual?
If so, What is that?

3. Are there any further aspects of this individual's behavior
or his interpretations of events that would be important
to know? If, briefly list them.

4. Recognizing that a psychiatrist has many options after an
initial interview assume you have the facts here, What
would you do if you saw this individual as a patient?

5. After taking a medical history, What are some of the important
questions (e.g., psychosexual development, mental state,
etc.) you would ask this individual?

6. ‘What circumstances would maximize the development of a
professional relationship between the individual and you?

7. What would you expect the developmental pattern to have
been in this reported behavior?

8. What is the responsibility of this individual?

9. What type of therapeutic environment do you see as beneficial
for this patient.

10. What would you consider a crisis situation for this individual?

11. What would be a resolution in this behavior?

Example Case #2
Individual is a female thirty years old. She expresses a

general hopelessness in her life. Her husband reports that she cries
at anything and that his efforts os settling her have little effect.

She complains of headaches, many minor aches and pains, fatigue,

and insomnia. She reports that She no longer desires to meet friends
and go out on the town for the night. She'has begun to neglect both

her housework and the management of her household. She reports to

having things too good all her life and being dissatisfied with

44

herself for not being able to enjoy her life. She places little

value on physical luxuries of life and also reports dissatisfaction

with any of her own achievements.

Questions

1.

2.

10.
11.

Is this reported behavior significant to you, as a
psychiatrist? If so in what way(s)?

Does this behavior signify to you a particular mode of
action of personal organization of this individual? If
so, what is that?

Are there any further aspects of this individual's behavior
of his interpretations of events that would be important

to know? If so, briefly list them.

Recognizing that a psychiatrist has many Options after an

initial interview assume you have the facts here, what
would you do if you saw this individual as a patient?

After taking a medical history, what are some of the important
questions (e.g., psychosexual development, mental state,
etc.) you would aSk this individual?

‘What circumstances would maximize the development of a
professional relationShip between the individual and you?

What would you expect the developmental pattern to have been
in this reported behavior?

What is the responsibility of this individual?

What type of therapeutic environment do you see as beneficial
for this patient?

What would you consider a crisis situation for this individual?

What would.be a resolution in this behavior?

Example Case #3

Individual is a male, thirty years old. He reports a general

sense of lineliness but expresses no desire for progressive

involvement in social relationShips. He guards his interactions

45

even with people Whom he has learned to trust. He enters social
relationships with a minimum of commitment so that he can exit
quickly if he feels it necessary. He reports common stomach upsets
and minor headaches. There is also an increasing sense of jumpiness
and he experiences uneasiness at the slightest provocation in social
relationships. He is aware of pe0ple watching him, following'him,
and, attempting to interfere with his activities. He also reports

a desire for constant travel and expresses high regard for the total

freedom that would allow'him to pick.up and take off at anytime.

Questions

1. Is this reported behavior significant to you, as a
psychiatrist? If so in What way(s)?

2. Does this behavior signify to you a particular mode of
action of personal organization of this individual? If
so, what is that.

3. Are there any further aSpects of this individual's behavior
or his interpretations of events that would be important
to know? If so, briefly list them.

4. Recognizing that a psychiatrist has many options after an
initial interview assume you have the facts here, what
would you do if you saw this individual as a patient?

5. After taking a medical'history, What are some of the
important questions (e.g., psychosexual development,
mental state, etc.) you would ask this individual?

6. 'What circumstances would maximize the deve10pment of a
professional relationship between the individual and you?

7. What would you expect the developmental pattern to have
been in this reported behavior?

8. ‘What is the responsibility of this individual?

9. What type of therapeutic environment do you see as beneficial
for this patient?

10. What would you consider a crisis situation for this individual?

11. 'What would be a resolution in this behavior?

l

. [[[[l|k{fl [{l‘llllul' (If.[liu[[.l|‘llll[ll’llal [I {III [I I'll. {I I .l i]

APPENDIX D

Questionnaire mailed to five superintendents of the state mental

hospitals.

1.

2.

It has been said that the State Mental Hospital no longer
exists in its traditional form.(i.e. long term."custodial"
care) but increasingly it serves as a‘backpup system to

city or community mental health efforts. To What extent
would you agree with that, and where would you differ?

The State.Mental Hospital is said to be increasingly involved
in research and professional training in addition to custody
and treatment. Is this a trend you have Observed? Can you
offer any predictions on future directions that state mental
hospitals might take.

Psychiatric treatment philosophy of public institutions is
sometimes characterized as oriented toward prevention and
crisis care. Enabling crises to be handled When and where
they are discovered and clients to be educated in their
capabilities, roles, resources, etc. To what extent is this
philosophy evident in state mental hospitals?

Heightened political activity and awareness, manifested in
such notions as civil rights for all and autonomy in decision
making, has served to underscore the plurality of our society.
Have these kinds of developments affected the operational
philosophy of the state mental hospital?

46

5.

47

It has been suggested that a concept of personal-social
determinism has supplanted an older personal-historical
determinism in psychiatry, resulting in stress on client
choice and responsibility. Is this evident to you in state
mental hospital psychiatry? If so, to what extent?

It has been further suggested that there is a focus on the
individual's acticn 3, current situations, capabilities, etc.
rather than'What he is, his history, his character, etc.

is - doing rather than being. To what extent do you see
emphasis on this in the state mental hospital?

 

. l . I. ,u . I. I
ll‘! .Iitlf‘i‘l llf'tl'li Ill-"ll l‘fll'ill‘flf ' Ill, [t I Hi ['1. Ill! .1.

"7'1? ii iiiflfliifl'ifii T