Hollingshead and Redlich: research on social class and mental illness fifty years after

Abstracts

This article examines the book Social class and mental illness: a community study by A.B. Hollingshead and F.C. Redlich as it marks the fifty year of its publication. It highlights the role of these researchers who, with distinct educational backgrounds (sociology and psychiatry), were part of the pioneering group in the 1950s that initiated the construction of medical sociology. Their careful methodological work and the fact that they approached an unprecedented topic ensured the originality of their project. The article analyzes the research and its importance for sociology and psychiatry, with emphasis on the studies regarding social classes, using the bibliographies as the main sources, critical analyses made of the work and related studies.

August de Belmont Hollingshead (1907-1980); Frederick Carl Redlich (1910-2004); social class and mental illness; social psychiatry; medical sociology

O artigo analisa o livro Social class and mental illness: a community study, de A.B. Hollingshead e F.C. Redlich, na marca dos cinquenta anos de sua publicação. Destaca o papel desses pesquisadores que, de formações distintas (sociologia e psiquiatria), fizeram parte do grupo pioneiro que nos anos 1950 iniciou a construção da sociologia médica. O cuidadoso trabalho metodológico e o fato de abordarem tema inédito garantiram a originalidade de seu projeto. Aborda a pesquisa e sua importância para a sociologia e a psiquiatria, com ênfase nos estudos sobre classe social, utilizando como principais fontes as bibliográficas, análises críticas feitas à obra e estudos afins.

August de Belmont Hollingshead (1907-1980); Frederick Carl Redlich (1910-2004); classe social e doença mental; psiquiatria social; sociologia médica

ANALYSIS

Hollingshead and Redlich: research on social class and mental illness fifty years after^*

Everardo Duarte Nunes

Profesor, Department of Preventive and Social Medicine/ Faculdade de Ciências Médicas/Universidade Estadual de Campinas. Rua Manoel Soares da Rocha, 320, Residencial Barão do Café 5 Barão Geraldo, 13085-055 - Campinas - SP - Brasil. [e-mail]

Translation by Glenn Ellefson.

ABSTRACT

This article examines the book Social class and mental illness: a community study by A.B. Hollingshead and F.C. Redlich as it marks the fiftieth year of its publication. It highlights the role of these researchers who, with distinct educational backgrounds (sociology and psychiatry), were part of the pioneering group in the 1950s that initiated the construction of medical sociology. Their careful methodological work and the fact that they approached an unprecedented topic ensured the originality of their project. The article analyzes the research and its importance for sociology and psychiatry, with emphasis on the studies regarding social classes, using the bibliographies as the main sources, as well as works of the authors and critical analyses made of the work and related studies.

Keywords: August de Belmont Hollingshead (1907-1980); Frederick Carl Redlich (1910-2004); social class and mental illness; social psychiatry; medical sociology.

August de Belmont Hollingshead and Frederick Carl Redlich were researchers who, coming from different educational backgrounds - sociology and psychiatry - collaborated in the 1950s and produced one of the most paradigmatic works of that decade: Social class and mental illness: a community study. Studying these authors, especially the contributions they brought to epidemiology, psychiatry and sociology, becomes of fundamental importance, since for the first time the concept of social class is associated with the problems of illness, in this case, mental illness, establishing a complex dialogue between medicine (psychiatry) and sociology that continues to the present day.

The topics constituted a challenge given the American creed, as they declare right at the beginning of their, research:

Americans prefer to avoid the two facts of life studied in this book: social class and mental illness. The very idea of "social class" is inconsistent with the American ideal of a society composed of free and equal individuals, individuals living in a society where they have identical opportunities to realize their inborn potentialities ... . Although Americans, by choice, deny the existence of social classes, they are forced to admit the reality of mental illness (Hollingshead, Redlich, 1958, p.3).¹

With this work, the authors joined the pioneering group that in the 1950s initiated the adventure of constructing a field of knowledge, medical sociology. Their careful methodological work and the fact that they approached an unprecedented topic ensured the originality of their project, which, published in 1958, was preceded by some 25 articles in the most prominent periodicals.

This article analyzes the work of Hollingshead and Redlich, highlighting its importance for the field of sociology and psychiatry. Fournier (2003, p.6) was very emphatic when stating: "today, there is a consensus on the fact that, even though a study is centered on the theoretical contributions of an author, it must contain not only biographical notes but also a contextualization of the work." The author recalls the distrust of sociologists with what Pierre Bourdieu (1996) called "the biographical illusion," since, as Fournier states (2003, p.6), "we must, in fact, always reconstruct the context, the 'social surface' on which the individual acts in a plurality of fields at each moment." Approaching these ideas, this article situates the trajectory of Hollingshead and Redlich and their contributions to medical/health sociology, especially concerning research on social class.

The authors

Contemporaries, Hollingshead² and Redlich³ worked at the same university, participated in the Second World War and experienced the problems of the postwar United States: the Cold War, the anti-communism captained by Senator Joseph McCarthy, the Marshall Plan - Program for European Recovery - and the creation of the North Atlantic Treaty Organization (Nato) and the United Nations (UN), among other events.

Without a doubt, the death of 405 thousand Americans between 1941 and 1945 (some statistics raise that number to 418,500) and the bombing of Hiroshima and Nagasaki profoundly marked American society for years. In the immediate postwar period, the United States faced serious economic and inflationary problems, together with intense activities of the working class, which pressured the creation of jobs through strikes. Intervention in the economic plan in the 1950s through control of the economy and an expansion in consumption would re-create the American dream of prosperity and conservatism. The analyses that so characterize this period are frequent: "During the 1950s, a sense of uniformity pervaded American society. Conformity was common, as young and old alike followed group norms rather than striking out on their own" (U.S. IPP, 2005, p.270).

On the other hand, that "conservatism and sense of uniformity" would have as a counterpoint the dissatisfaction that, originating in the 1940s, would manifest itself in what is considered the first counterculture movement - the so-called beatnik generation - whose emblematic figures are Ginsberg, Kerouac and Burroughs. In addition, at the end of the 1950s another important movement would appear, the one opposing racial segregation and resulting in The Civil Rights Act of 1957, which authorized federal intervention in cases of discrimination against blacks in schools and their right to vote.

In addition to economic, political, social and cultural transformations, those directly related to issues of health and its political organization are of great relevance. The question of a national health program had been discussed in the United States since the mid-1930s, continuing in the postwar period, but meeting resistance, especially from the American Medical Association. Even the recommendations for hospital insurance in official budgets did not have an effect and the growing costs of medical attention increased private insurance, events that have dragged on to the present day. The war itself stimulated progress in research and led the government to make the product of discoveries such as antibiotics available to everyone. Aiming to accelerate the formation of 'doctors for wartime', medical courses, which had a duration of four years, were completed in three, which was criticized by some professionals, who argued about the possibility of a superficial education. This is also an age marked by expansion of government support to medicine and the effective increase of doctors for the Army, whose number rose from 1,200 in peacetime to 46,000 as an effect of the war.

With respect to psychiatry, the experience in the Second World War was different from that which had occurred in the First. There are many analyses of the role played by the Second World War for psychiatry as a field of knowledge and practices. Chosen for being emblematic were some ideas that appeared in the Introduction to Mental health in the metropolis: the midtown Manhattan study (Srole et al., 1962), by Alexander H. Leighton (1908-2007), still today considered basic for the epidemiological knowledge of mental diseases and that, at the time of its publication, galvanized public opinion because of the impact of its findings.⁴ In this Introduction, Leighton (1962, p.VII) distinguishes that, before the Second World War, few behavioral scientists had interested themselves in the effects of social and cultural questions on mental illness, and even within psychiatry little attention was paid to the topic, with some exceptions, Adolf Meyer among them. At the end of the conflict, studies relating social cultural aspects to the etiology of psychiatric disorders grew. Leighton, who had been at the front in the Second World War and participated intensely in postwar activities, especially on research regarding the impact of the atomic bomb on the Japanese civil population, states that there are many reasons that led to an "upsurge of interest" in the topic of mental disease. For him, "some were diffuse and part of the general shaking up experienced by people everywhere," but others "reflected greater awareness of the severe emotional problems confronting mankind in a changing society." He points out that another factor was the evidence of the high prevalence of psychiatric disorders found during the military service selection process and, after, the problems of rehabilitating the psychiatrically incapable.⁵

Another point concerns the patients. Now, they are "treated with hope and with much success," and psychosis and neurosis come to be seen as the product of a complex set of factors (Bloom, 2002, p.118-119). In general, the main change in American psychiatry after the Second World War was moving from a predominantly biological perspective to a psychodynamic one, but, as Menninger and Nemiah (2000, p.XXII) observe, the alternation of these two perspectives is cyclical in psychiatry. Without a doubt, these aspects influence both the way studies are conceived and the relationships between psychiatry and the social sciences, the work of Hollingshead and Redlich being exemplary of the postwar moment.

In addition to these aspects, it is important to situate in this scenario Yale University, which had a pioneering role in the field of sociology and medical sociology. Located in New Haven, Connecticut, it is one of the most traditional schools in the United States - its origins date back to 1701. It was there, in 1876, that William Graham Sumner offered the first course in sociology in the United States. When highlighting the importance of this institution in the field of medical sociology, Bloom (2002, p.136) points out the role of Hollingshead, who transformed Yale into a reference point in the institutionalization of his field. First, choosing New Haven as a place for studying the relationships between social class and mental disease; second, creating an inaugural program for training in medical sociology; and third, forming the Committee on Medical Sociology in 1955, a pioneer organization of sociologists focused on the field of health and disease.

Hollingshead followed the tradition started in the 1930s by Leo Simmons, who had already taught health sociology at Yale and who, together with Harold Wollf, would write the first textbook entitled Social science in medicine in 1954. Syme (2005), one of the four students in the first medical sociology class at Yale, reveals, in an autobiographical description, the beginnings of this course, when he opted for sociology in medicine, which for him meant "the study of how social factors affect health and well-being," and highlights the vanguard role of Hollingshead and Redlich.

As the biographers of Hollingshead and Redlich analyze, the relations between the two researchers, even though extremely productive, were not always easy. In an interview with Bloom (2002, p.151), Redlich stated: "Sandy and I were very different people." He added, however, that they complemented each other in the partnership in 1948, when psychiatry and sociology left their isolation, a fundamental event for interdisciplinary research. Once again, recourse to the text of Bloom (2002) and his interviews is indispensable. Gene Brody, for example, declares:

Fritz Redlich, very much the bridging person, who connected the newly vibrant social, biological and psychoanalytic streams in the department, was fond of an expression which I have plagiarized from time to time. Psychiatry, he said, rests on a tripod. One leg is made up of the medical and biological sciences; one, of what we learned form psychoanalysis and psychotherapy; the third, of experimental psychology and the sciences of social structure and culture, such as sociology and anthropology (p.153).

In Bloom's opinion, other consequences of this moment should be pointed out. For psychiatry, for example, the area of social psychiatry studies was created and for sociology, the medical sociology field was opened. In this regard, as already remarked, Yale played a central role in this field in terms of innovative programs between 1930 and 1950, when "medical sociology was not yet even used as a descriptive name" (Bloom, 2002, p.153).

In the following years, although Yale University maintained its prominence in this field, the strongest force would come from another institution, the National Institute of Mental Health (Nimh). Created in April 1949, its greatest development started in the second half of the following decade, becoming, over the years, the greatest organization in the world devoted to research on mental disease, with the effective participation of social scientists - especially sociologists - in its staff of researchers.

Interdisciplinary research

When Hollingshead and Redlich met each other in 1947-1948, both already had recorded achievements in their respective fields, which served to leverage their intentions to render an interdisciplinary project concrete. Hollingshead, who had initiated his research on human ecology with a thesis on the ecological and institutional process in 34 communities of Nebraska (Myers, Straus, 1989, p.2) and a series of articles on human ecology dated 1939 (Pierson, 1948), returned in the 1940s to issues of social stratification. His study of adolescents in Elmtown dates from this time, as part of his post-doctorate studies at the University of Chicago. His hypothesis was that "the social behavior of adolescents appears to be related functionally to the position their parents occupy in the social structure of the community" (Hollingshead, 1949, p.9). Interrupted for three years, while Hollingshead served in the U.S. Army Air Force, the project was resumed in 1949, when his results were published. The findings that prove the hypothesis of the relationships between the behavior of adolescents and their families' social position received the following appreciation of Myers and Straus (1989, p.3):

These findings not only contributed significantly to sociological theory of social stratification but had equally important implications for social policy. In the conclusions to Elmtown's Youth, Hollingshead pointed out the conflict between the class system and the ideas of official America embodied in the Declaration of Independence and the Constitution and the American creed. In retrospect, the book was clearly of as much value to educators as to social scientists.

As a result, when initiating a new project, Hollingshead brought with him the experience of his previous work on the topic of social stratification.

Similarly, Redlich, before working with Hollingshead, had produced important works and co-authored two books: Psychotherapy with schizophrenics, in 1952 with Eugene B. Brody (Brody, Redlich, 1952), and The initial interview in psychiatric practice, in 1954 with Merton Gill and Richard Newman (Gill, Newman, Redlich, 1954).

The theme of research that culminated with the publication of Social class and mental illness: a community study in 1958 was not unprecedented, since the researchers had already published works in co-authorship, individually and with other collaborators. From 1952 to 1957, they prepared 25 articles - a list of which is found on pages 16 and 17 of the 1958 book - some presented at scientific meetings and a large part published in various periodicals, dealing with social stratification and mobility, and the treatment of mental illnesses etc., the scenario for which was the city of New Haven, Connecticut.

In this work, which covered five decades, the authors carried out a careful empirical study on topics that were taboos for American society - as we said - initially reviewing them: "We found that the question of relationship between an individual's position in the class structure and the kind of mental illness he develops, on the one hand, and the treatment he receives for it, on the other, had not been studied extensively by either psychiatrists or sociologists. Only a few speculative research papers had dealt with this question before 1950" (Hollingshead, Redlich, 1958, p.7). They added the studies on mental disease that had already been conducted by doctors and sociologists: the psychiatrists gave priority to biological, psychological and physical aspects, and the sociologists, to human ecology and social disorganization. They emphasized the fact that psychiatrists and social scientists had developed their theories independently, observing that "few efforts have been made to bridge the gap between the two kinds of theory." A classical theme of the social scientists since the origins of sociology, the social classes, they observed, had been ignored by psychiatrists up to the 1950s. In Freud, there is only a passing reference in Introductory lectures, and other psychiatrists, such as Adler, Horney, Erikson, did not linger on the subject, probably due to the strong influence of the biological sciences on the field of psychiatry.

With the expression "to bridge the gap", referring to their departure from the theoretical positions of these fields of knowledge, Hollingshead and Redlich (1958) indicated the central objective of their research. They had two central questions: (1) is mental illness related to class in our society? and (2) does the position of a psychiatric patient in the social structure affect the manner in which he is treated for his illness? Hollingshead and Redlich associated the first question to etiology, developing the following reasoning: if different social classes exhibit different lifestyles, it can be conjectured that the emotional problems of individuals can be related to the standards of life characteristic of their class situations. The second question concerned the possibility of treatment depending not only on the state of medical knowledge, with social processes and psychologists being important determinants in this choice, but also on pursuing the case. These questions generated three hypotheses regarding the relationships between the position of the individual in the class structure (1) and the prevalence of the disease treated; (2) and the type of psychiatric disorders diagnosed; (3) and the type of treatment administered by the psychiatrists. In addition to these, another two hypotheses sought to respond to the associations between social and psychodynamic factors in the development of psychiatric disorders: mobility in the class structure and the development of psychiatric problems. The test of these hypotheses was meticulously planned based on methodological procedures that considered enumeration of the individuals that were receiving psychiatric treatment, the selection of a population sample, determination of the patient's place in the class structure, detailed information on the practice of psychiatry and the clinical study of fifty patients and their families included in the case control study.

The authors traced the historical evolution of the social structure of the community of New Haven, from the colonial era (1638-1818), going through the industrialization and immigration phase (1820-1914), until the period was reached that the authors denominate acculturation (1915 to the time of the investigation). They characterized the current state observing: "The community's current status structure is differentiated both vertically and horizontally by lines of cleavage which hold some groups together, while they simultaneously separate them from other groups" (p.64). The vertical division was established by racial, ethnic and religious characteristics, and the horizontal, by the variables of occupation, education and place of residence.

The point of departure of social stratification, according to Hollingshead, was based on three assumptions: (1) that stratification existed in the community; (2) that the status of individuals was mainly determined by a small number of cultural characteristics accepted by the community; and (3) that the symbolic items of status could be graded and combined through the use of statistical procedures so that a researcher could rapidly stratify the population confidently and significantly. These assumptions constitute the basis for construction of the Index of Social Position, (ISP), whose variables are: place of residence; occupational position of the head of the family; and years of schooling completed by the head of the family. This index is described in detail in Chapter IV (p.66-135) and in the Appendix (p.387-397), when Hollingshead relates the origins of the scales and explains that, for residents, the scores varied from 1 to 6 and for occupation and education, from 1 to 7. To compute the ISP, factor weights of 5, 6 and 9 were established, based on a multiple regression equation. When the scores were computed, each family was compared in a continuum established for each class.⁶ Finally, the structure of the community's classes was established as follows:

- Class I: comprised of leaders in administration and industry and community professionals having the highest incomes; men with university degrees and women with 1 to 4 years of high school education; traditional families, descendent from the pioneers, who dominate the private clubs, with values that characterize them as "socially responsible for its members and the welfare of the community."

- Class II: comprised of families whose members have a high school education and often higher; the men occupy administrative positions and are engaged in professions classified in a lower level; they are wealthy families thanks to a fortune acquired more than inherited; 9.8% of families are situated in that stratum.

- Class III: comprised of small proprietors, employees and skilled labor; children of these families more often study in technical high schools and, sometimes, in universities; they live in good residential areas, but frequent different clubs from classes I and II; significantly, more men than women are dissatisfied with their current situation in life and less optimistic about the future; 18.9% of the families were classified in this stratum.

- Class IV: comprised of semi-skilled workers, who only attended grammar school; they feel secure in their economic position, but not totally satisfied with their situation in life; their children are dissatisfied; they don't belong to clubs; and their leisure activities are limited to television, listening to the radio, going to the movies and taking rides; the men participate in unions; they live in less well-to-do neighborhoods; 48.4% of the families fall within this category.

- Class V: comprised of unskilled workers, most of whom have not completed primary school; they live in less desirable areas, including tenement houses; their social lives are limited to the family, the neighbors, the street or community social agencies; the adults resent how they are treated by their bosses and other members of the community; 20.2% of the families are found in this grouping.

This synthesis does not reveal the extreme acuity or degree of detailing with which the authors studied the structure of the community. They included in the research the perception of people regarding their belonging to a given class - the question offered eight choices: 'upper', 'upper medium', 'medium, 'lower medium', 'working', 'low, 'don't know' and 'I don't believe in classes' - and which elements determine belonging to the different classes.

The quantity of results makes a detailed presentation of the relationships encountered in the research impractical. We highlight some of the conclusions.

- Number of mentally ill: The greatest concentrations are in classes IV and V, 38.6% and 36.8% respectively; 13.2% in class III; 6.7% in class II; 1% in class I; and 3.7% not identified.

- Types of mental illness: a greater concentration of neuroses in class II (67.2%) and class I (52.6%), diminishing in the less privileged classes, 44.2% (class III), 23.1% (class IV) and 8.4% (class V); a greater concentration of psychoses in classes V, IV and III (91.6%, 76.9% and 55.8%, respectively), diminishing in classes I (47.4%) and II (32.8%). As for schizophrenia, the percentages vary from 0.7% in class I to 45.2% in V. The prevalence of greater indices in the less favored classes is present both in the first hospitalization and the relapses, acute crises and chronic disturbances.

- The types of treatment are strictly related to the classes: psychotherapy predominates in class I (73.7%) and II (81.7%); organic therapy, in classes IV (37.1%) and V (32.7%); and no treatment in class V (51.2%).

The analyses of Hollingshead and Redlich (1958, p.2l6) evidenced a clear association between class position and the fact of being a psychiatric patient: class V almost invariably contributed many more patients than their proportion in the population, and between the higher classes the relationship is more congruent. When the authors analyzed other variables such as sex, age, race, religion and marital status, maintained as constants among the various classes, they verified that the association between social class and mental illness reappeared.

A year after Social class and mental illness was published, the research conducted by Myers and Roberts (1959) appeared. It enjoyed supervision by Hollingshead and Redlich and was then considered the second part of the pioneering work. Two issues are approached there, social class position and mobility, related to social and psychodynamic factors in the development of psychiatric disorders. Fifty patients, with their families, were studied in classes III and V - 25 'psychoneurotics' and 25 'schizophrenics' -, for the purpose of verifying family relationships during infancy, community pressures on the patients and the symptoms presented. Pasternak (1960, p.164), reviewing the book, pointed out that the research encountered "Significant differences affecting the character and intensity of mental disorders were observed between the two classes." Thus, patients in class III "accepting such values as respectability and responsibility, turned their frustrations inward into psychological conflicts and appeared more sensitive to internal threats, fears, and guilts than did lower-class patients." Patients of class V "gave more direct expression to their instinctual impulses, which led to less inhibition and fewer immediate frustrations." On the other hand, efforts toward upward mobility provoked tensions among patients of class III.

Many other researchers have expressed themselves about this work, among them Linford Rees (1914-2004), a prominent British psychiatrist in the second half of the twentieth century, who stated: "This is an important book meriting serious study by everyone interested in social aspects of psychiatry" (Rees, 1962, p.234).

Social class and mental illness: the criticism

The impact of the work of Hollingshead and Redlich, which received the MacIver Award of the American Sociological Association (ASA) in the year following that of its publication, was very great, but not free of criticisms.

Before Myers and Bean (1968) made an assessment of this research, Roger Bastide (1898-1974) analyzed the New Haven study in detail. According to the French sociologist, criticisms of the work can be classified in two groups, depending whether they concern the methodology or the interpretation. Having recourse to the study of Kaplan, Reed and Richardson (1951), Bastide (1968a) argued that the data relative to hospitalized cases could present a bias, since patients of the higher classes would be treated in their homes or in private clinics and not in hospitals, and thus "the psychotics hospitalized would not give us a valid picture of the distribution of mental disturbances according to class" (p.138). As for interpretation, the study of the New Haven community did not discover any correlation between the social classes and mental disturbances, both for men and women, in the age group of 15 to 24 (Hollingshead, Redlich, 1958, p.217). Furthermore, according to Bastide's commentary, the authors found a relationship between family disorganization and psychic disorganization, which led him to ask which would be the more important explicative factor, social position or family disorganization, even considering that this disorganization varies a great deal according to social stratum.

According to Myers and Bean (1968), decisions regarding the type of treatment and hospitalization are influenced by the patient's social class, but there is no evidence that class had been a relevant factor or that people had taken such decisions aware of the patient's class position. The authors emphasized that it can be confirmed from Hollingshead and Redlich's research that social class is associated with the type of treatment and the readmission experience.

Some time afterwards, Haug and Sussman (1971a) developed a detailed analysis of the social class indices used by Hollingshead (the ISP) and included a study on the Socio-Economic Index (SEI) of B. Duncan. The authors were compelling when observing: "The indiscriminate state of the social class concept in contemporary sociology is not the responsibility of Hollingshead and Duncan, although the stratification measures they created are so simple and useful as to mask the underlying state of affairs" (p.550-551). With respect to Hollingshead, they stated that "the scheme is in urgent need of updating" (p.551), and recalled that the problem of constructing a 'standard-scale' of social class was critical. As is known, that topic would accompany successive discussions regarding operationalization of the concept of social class, especially in epidemiological studies. Hollingshead (1971) refuted the criticisms, arguing that working with concepts that make up part of the history of sociology is a difficult task - it should not be forgotten that they come with the stamp and authority of the classics, in this case Marx and Weber. He added that the authors of the criticisms had not considered the long journey that preceded publication of the ISP. He detailed many points about two factors - occupation and education - used as measures of social class, agreeing with his critics regarding a "careful appraisal of the definitions and measurements of occupational and educational inequalities by sociologists and other behavioral scientists" (p.567) being fundamental. In reply, Haug and Sussman (1971b) reiterated that the measures used did not measure what they proposed, "partly due to the haziness of the concept being operationalized" (p.569).

Accompanying the trajectory of Hollingshead and Redlich's research to when it was 25 years old and a considerable mass of studies had arisen, we arrive at the end of the 1980's, with the review written by Mollica and Milic (1986a), who then stated: "These studies have lead to a general acceptance within the psychiatric profession that, in addition to medical criteria, latent social factors can be influential in the determination of who is treated where, how, and by whom" (p.12). As part of the Trends in Mental Health project, which continued the studies of the 1950s, the results of the relationships between social class and admission for out-patient treatment in the regional area of the Community Mental Health Center (CMHC) of New Haven were presented. "Multivariate analysis was used to determine the relative predictive power of social class as compared with other class-related variables such as occupation, education, employment history, sociodemographic characteristics (e.g. age, race, and sex) and diagnosis." This information was collected in interviews to which the patients were submitted when they arrived for treatment in the Center. The course of treatment and the final diagnosis were analyzed the year after the initial interview. In its conclusions, the study revealed three new important tendencies compared with that of Hollingshead and Redlich in 1958: (1) patients in the lowest class (class V) had access to public out-patient treatment in the CMHC, representing almost 50% of all of the patients (it should be recalled that, in the 1958 study, most of the patients that sought treatment belonged to classes III and IV); (2) more than half (60%) of all of the patients that sought evaluation in the CMHC were dismissed without scheduling an appointment in a treatment unit; and (3) the lower the class of the patient, the less the probability of being attended in the psychotherapy unit. When reviewing the model, Mollica and Milic pointed out that the first factor to affect the type of care is gender - more men than women were sent to psychotherapy. The second factor is the diagnosis - drug users and alcoholics were excluded from treatment. The third factor is connection with the job market - being well employed favored opportunities for treatment, in other words, "chronically unemployed patients had the least chance of being referred to psychotherapy (in spite of having been diagnosed as having psychoneurosis)" (p.16). The authors also referred to other studies that show the influence of color and found that black patients have little opportunity to receive professional psychotherapeutic treatment.

Mollica and Milic (1986b) produced another work expanding the 1975 results (Trends in Mental Health project), studying the distribution (prevalence) of psychiatric care to hospitalized patients and comparing it with the data of 1950. The study reaffirmed that "discriminate function analysis reveals that social class remains a major predictor of [the] locus of psychiatric impatient care" and evidences the economic barriers to private hospital treatment, especially women from the lower classes, blacks and those with serious psychiatric disorders. Thus, although social class still remained as an important tool, it can be perceived that "its effects are confounded by other social factors, such as gender and race" (p.109).

Subsequent surveys such as those of Ortega and Corzine (1990) were conducted on the relationships between social class and mental disease. Of the total of sixty research works, 46 disclosed an inverse relationship between social class and the prevalence of mental illness - higher rates in the lower classes. It should be recalled that at the end of the 1960s, Dohrenwend and Dohrenwend (1969) found 25 studies, of which twenty revealed the same relationship.

Revisiting the classic of medical sociology prepared by Hollingshead and Redlich is also to think about the category itself, for which it was utilized and operationalized in their research - social class, a topic that passes through the history of sociology, being continually debated. But going into the matter in greater depth exceeds the interests of this work. Without a doubt, the question still remains present, as Giddens (2005, p.251) analyzes: "Despite the traditional domain of class, in certain aspects, indubitably undergoing a weakening process, especially with respect to the identity of people, class divisions remain at the core of the central economic inequalities of modern societies." In general, the issue that is put forth by research on social class, including that of Hollingshead and Redlich, concerns the fact that this concept is difficult and complex to operationalize with respect to both sociology and epidemiology. At the end of the 1990s, Solla (1996) prepared a detailed analysis of the subject, bringing the main contributions of Latin American researchers. He retrieved some of the most cited studies that attempted to operationalize the concept of social class, such as those of Barros (1986), Bronfman and Tuirán (1984) and Bronfman et al. (1988). Their works focused on the perspective of "identifying classes according to their structural connection and not by their effects (such as: income, educational level and other characteristic components and derivatives of insertion)" (Solla, 1996). He recalled, meanwhile, that beginning in the 1990s, the studies based on this Marxist pillar tapered off. As an unresolved issue, the operationalization and utilization of variables that characterize the classes and are capable of stratifying social reality continue to challenge the studious. As the most recent analyses in the area of health sociology show, a growing discussion regarding the role that class position plays in the distribution of health and illness in human populations has been taking place (Cockerham, 2007).

If the question of social classes continues to challenge social scientists, the same can also be said about the topic of measurement for psychiatrists. Horwitz (2002) establishes four phases that characterize the trajectory of the studies, preceded by the utilization of official statistics as measurements of mental illness during the 19th century. The first phase, the 1930s, is characterized by utilization of the cases treated, the New Haven research being a prototype of that time, followed, in the 1950s, by research with members of the community, using the "self-reported symptom scales" (p.144), which inaugurated the second phase. The third phase, in the 1980s, conducted investigations that are characterized by the use of diagnostic entities established by psychiatrists through the DSM-III and applied in community studies. The text establishes a dialogue between the ways of measurement and what constitutes "good sociological measures of mental health and illness" in the outlook of these three phases and points to the opening for development of the fourth, that of the "sociologically sensitive indicators" (p.148). Prominent in this area is the message, extremely well-prepared, that Mirowsky and Ross (2002, p.152) offered to measure the human condition, when they announced in their article "Measures of mental health should represent and assess elements of human experience clarified and refined from that experience but not removed from it. Research in mental health speaks most true when it takes measures of life as a people feel it, sense it, and experience it."

In addition, as Oakes and Rossi (2003) point out, the question of the construction and validation of social economic indices is still misinterpreted for the fields of social and behav-ioral sciences, requiring the attention of researchers and social epidemiologists.

Final considerations

It is difficult to classify certain studies in relation to fields of knowledge, because they are do not fall exclusively within a given disciplinary area. The study of Hollingshead and Redlich falls into this category; it opens new fields (and that is how it should be seen) such as social psychiatry, medical sociology and psychiatric epidemiology, and when it was produced, at the end of the 1950s, it makes this approximation an event that would mark this pioneering research (Pols, 2007).

Without a doubt, many changes have occurred in five decades. This includes the relationships between sociology and psychiatry, which underwent profound transformations beginning in the 1970s. For Pilgrim and Rogers (2005), these disciplines took different roads; psychiatry, with methodological concerns, returned to a biomedical approach; social psychiatry, underpinned by the biopsychosocial model, became marginalized and weakened; in turn, many sociologists transferred their interests in psychiatry and methodological research to studies of mental health problems, using a theoretical perspective and the application of a qualitative methodology. Accompanying this, according to these authors, is the exhaustion of the interdisciplinary perspective in mental health. As we can see, the pioneering of the 1950s, after many conquests that seemed very promising - even if we consider, with Bastide (1968b), that the interdisciplinarity of Hollingshead and Redlich's research is still categorized by a "stratified coexistence," i.e., the diagnosis is made by the psychiatrist and the sociologist establishes the relationships - continues to be an area open to discussion and innovation.

Without a doubt, in one way or another, anti-psychiatry and the anti-insane asylum struggle inherited the findings of many of the studies that have touched social, political and cultural aspects since the end of the 1950s and, with greater strength, in the next decade, and were able to redirect the issue to the field of mental health (and not just mental illness).

With a good deal of propriety, Blair Wheaton (2001) observed that in the relations between sociology and mental health disciplines, "if there is a 'latent variable' in this talk, it is the interaction between two themes: structural position vs. analytic power" (p.233). For him, both the internal look of sociology as well as the external - "words beyond our immediate network" (p.233) - are fundamental for orienting research involving mental health; furthermore, as in the title of his article, "the role of sociology in the study of mental health ... and the role of mental health in the study of sociology" has to be considered. This perhaps causes a return to the collaborative synergy, to use the expression of Pilgrim and Rogers (2005, p.319), that existed between psychiatrists and sociologists, but, as these English researchers analyze, concessions would be required from both parties.

Myers and Straus (1989, p.5-6), when drawing the sociological profile of Hollingshead, point out that the research that he conducted "contributed significantly to our understanding of the influence of social class upon human behavior", and they highlight social class as the central theoretical concept of sociology. After the New Haven study, two other works of Hollingshead would be remarkable for the field of medical sociology: in collaboration with Lloyd H. Rogler (1930-), the study of mental disease in families of Puerto Rico (Rogler, Hollingshead, 1965) and, with Raymond S. Duff (1923-1996), a revealing analysis of the relationships between the care given hospitalized patients and the social environment in a university hospital (Duff, Hollingshead, 1968). Rogler expressed himself as follows on Hollingshead: "It is commonly recognized that Sandy's lifetime work represents a monumental contribution to our understanding of the human scene." This, according to the author, was obtained by "his commitment to the belief that the complexity of the social world imposed upon sociologists the responsibility of rendering accounts with economy and forthrightness" (cited in Myers, Straus, 1989, p.4).

Redlich is remembered not only for his academic works in the area of psychiatry, but also as one of the creators of social psychiatry, an innovative administrator in the medical school and Department of Psychiatry at Yale University, and co-founder of The Yale-Connecticut Mental Health Center. His practice of integrating knowledge of the biological sciences (especially neurology), the behavioral sciences (psychology and sociology) and psychoanalysis into clinical work marked his passage through university life.

As I stated previously, the work of Hollingshead and Redlich should be understood in the context in which it appears, as well as expressing the experiences of the authors themselves in the search for an explanation of relevant events in the historical period when they researched. Furthermore, when they wrote their work, medical sociology was also seeking a form of expression. At the end of the 1950s, Renée Fox, Robert Merton, George Reader, Patricia Kendall, Jerome Myers, Leo Srole, Robert Straus, Samuel Bloom and, right after, Howard Becker and Elliot Freidson would be pioneers in the fields of the study of disease, of medical education, of deviation and of the medical profession, and indelibly marked the trajectory of medical sociology in a scenario that has to include both Hollingshead and Redlich.

NOTES

REFERENCES

• BARROS, Marilisa Berti de Azevedo. A utilização do conceito de classe social nos estudos dos perfis epidemiológicos: uma proposta. Revista de Saúde Pública, São Paulo, n.20, p.269-273. 1986.
• BASTIDE, Roger. Sociologia das doenças mentais Trad., Ramiro da Fonseca. Lisboa: Publicações Europa-América. 1968a.
• BASTIDE, Roger. Approche interdisciplinaire de la maladie mentale. In: Unesco. Les sciences sociales: problèmes et orientations. Paris: Unesco. p.435-450. 1968b.
• BLOOM, Samuel W. The word as scalpel: a history of medical sociology. New York: Oxford University Press. 2002.
• BOURDIEU, Pierre A ilusão biográfica. In: Bourdieu, Pierre. Razões práticas: sobre a teoria da ação. Trad., Mariza Correa. Campinas: Papirus. p.74-82. 1996.
• BRODY, Eugene B.; REDLICH, Frederich C. (Ed.). Psychotherapy with schizophrenics New York: International Universities Press. 1952.
• BRONFMAN, Mario et al. Operacionalização do conceito de classe social em estudos epidemiológicos. Revista de Saúde Pública, São Paulo, v.22, n.4, p.253-265. 1988.
• BRONFMAN, Mario; TUIRÁN, Rodolfo. La desigualdad ante la muerte: clases sociales y mortalidad en la niñez. Cuadernos Médico-Sociales, Rosario, n.29-30, p.53-75. 1984.
• COCKERHAM, William C. Social causes of health and disease Cambridge: Polity. 2007.
• DOHRENWEND, Bruce. P.; DOHRENWEND, Barbara S. Social status and psychological disorder. New York: John Wiley & Sons. 1969.
• DUFF, Raymond; HOLLINGSHEAD, August B. Sickness and society New York: Harper & Row.
• FOURNIER, Marcel. Para reescrever a biografia de Marcel Mauss... . Revista Brasileira de Ciências Sociais, São Paulo, v.18, n.52, p. 5-13. 2003.
• GIDDENS, Anthony. Sociologia. Trad., Sandra Regina Netz. 4. ed. Porto Alegre: Artmed. 2005.
• GILL, Merton; NEWMAN, Richard; REDLICH Frederich C. The initial interview in psychiatric practice New York: International Universities Press. 1954.
• HAUG, Marie R.; SUSSMAN, Marvin B. The indiscriminate state of social class measurement. Social Forces, Chapel Hill, v.49, n.4, p.549-563. 1971a.
• HAUG, Marie R.; SUSSMAN, Marvin B. Reply to Hollingshead. Social Forces, Chapel Hill, v.49, n.4, p.568-569. 1971b.
• HOLLINGSHEAD, August B. Commentary on 'The indiscriminate state of social class movement'. Social Forces, Chapel Hill, v.49, n.4, p.563-567. 1971.
• HOLLINGSHEAD August B. Elmtown's youth: the impact of social classes on adolescents. New York: John Wiley & Sons. 1949.
• HOLLINGSHEAD, August B., REDLICH, Frederich C. Social class and mental illness: a community study. New York: John Wiley & Sons. 1958.
• HORWITZ, A.V. Outcomes in the sociology of mental health and illness: where have we been and where are we going? Journal of Health and Social Behavior, Washington, v.43, n.2, p.143-170. 2002.
• LEIGHTON, Alexander H. Foreword. In: Srole, Leo et al. Mental health in the metropolis: the midtown study, I. New York: McGraw-Hill Book. p.VII-IX. 1962.
• MENNINGER, Roy W.; NEMIAH, John C. American psychiatry after World War II. Washington, DC: American Psychiatric Press. 2000.
• MIROWSKY, John; ROSS, Catherine E. Measurement for a human science. Journal of Health and Social Behavior, Washington, v.43, n.2, p.152-170. 2002.
• MOLLICA, Richard F; MILIC, Mladen. Social class and psychiatric practice: a revision of the Hollingshead and Redlich model. American Journal of Psychiatry, Arlington, n.143, p.12-17. 1986a.
• MOLLICA, Richard F; MILIC, Mladen. Social class and psychiatric inpatient care: a twenty-five year perspective. Social Psychiatry and Psychiatric Epidemiology, Berlin, n.21, p.106-112. 1986b.
• MYERS, Jerome K.; BEAN, Lee L. A decade later: follow-up of social class and mental illness. New York: John Wiley &Sons. 1968.
• MYERS, Jerome K.; ROBERTS, Bertram H. Family and class dynamics in mental illness New York: John Wiley & Sons. 1959.
• MYERS, Jerome K.; STRAUS, Robert. A sociological profile of August B. Hollingshead. Sociological Inquiry, Malden, v.59, n.1, p.1-6. 1989.
• OAKES, J. Michael; ROSSI, Peter H. The measurement of SES in health research: current practice and steps toward a new approach. Social Science & Medicine, Oxford, v.56, n.4, p.769-784. 2003.
• ORTEGA S.; CORZINE, J. Socioeconomic status and mental disorders. Research in Community and Mental Health, n.6, p.149-182. 1990.
• PASTERNAK, Walter P. [Review of] 'Family and class dynamics' by Jerome K. Myers and Bertram Roberts. Psychosomatic Medicine, New York, v.22, n.2, p. 164. 1960.
• PIERSON, Donald (Org.). Estudos de ecologia humana: leituras de sociologia e antropologia social. São Paulo: Martins Fontes. 1948.
• PILGRIM, David; ROGERS, Anne. The troubled relationship between psychiatry and sociology. International Journal of Social Psychiatry, London, v.51, n.3, p.228-241. 2005.
• POLS, Hans. August Hollingshead and Frederick Redlich: poverty, socioeconomic status and mental illness. American Journal of Public Health, Washington, v.97, n.10, p.1755. 2007.
• REES, W. Linford. [Review of] 'Family and class dynamics' by Jerome K. Myers and Bertram Roberts. British Journal of Psychiatry, London, v.108, p. 234. 1962.
• ROGLER, Lloyd H.; HOLLINGSHEAD, August B. Trapped: families and schizophrenia. New York: Wiley. 1965.
• SOLLA, Jorge José Santos Pereira. Diferenças nas propostas de operacionalização do conceito de classe social empregadas em estudos epidemiológicos. Cadernos de Saúde Pública, Rio de Janeiro, v.12, n.3, p.329-337. 1996.
• SROLE, Leo et al. Mental health in the metropolis New York: MCGraw-Hill. 1962.
• SYME, S. Leonard. Historical perspective: the social determinants of disease - some roots of the movement. Epidemiological Perspectives & Innovations, 2. 2005.
• U.S. IPP. U.S. State Department's Bureau of International Information Programs. Postwar America. In: U.S. IPP. Outline of U.S. history Disponível em: http://www.america.gov/media/pdf/books/historytln.pdf#popup Acesso em: 29 jan. 2010. 2005.
• WHEATON, Blair. The role of sociology in the study of mental health ... and the role of mental health in the study of sociology. Journal of Health and Social Behavior, London, v.42, n.3, p. 221-234. 2001.

*

This article is part of the History of Health Sociology Project, which enjoys the financing of the CNPq - Bolsa Produtividade (Productivity Scholarship).

1

In text citations other than English, the translation is free.

2

August de Belmont Hollingshead was born in Lyman, Wyoming in 1907. He studied at the University of California, Berkeley, where he received a bachelor's degree in 1931 and his master's degree in sociology in 1933. He pursued his doctorate at the University of Nebraska, concluded in 1935, then moving on to develop teaching activities in various American universities (Iowa, Alabama, and Indiana), which were interrupted between 1943 and 1945, during the Second World War, when he enlisted in the U.S. Army Air Force, attaining the rank of First Lieutenant. Resuming his teaching activities, he lectured at Yale, where in 1952 he became professor of sociology and headed the department from 1959 until 1965. In addition to visiting professor at various universities, he was an advisor to the Surgeon General of the United States, the highest authority in the area of health in that country, and a member of the National Association for Retarded Children in 1960. Having turned his interests to the topics of medicine, psychiatry, patients and mental illness, he became one of the pioneers of medical sociology. He died in 1980.

3

Frederick Carl Redlich was born in Vienna in 1910, where he received a diploma in medicine in 1935 and did his internship and residency. He instituted psychoanalytical treatment at the Vienna Institute of Psychoanalysis in 1937 and the following year emigrated to the United States, where he did his medical residency in neurology and psychiatry. He joined the Medical College of Yale University in 1942. He became a naturalized American citizen in 1943, participated in the Second World War from 1944 to 1945 and received his psychoanalyst certificate in 1953. At that time, he was already head of the Department of Psychiatry at Yale, where he was a director at the Medical College from 1967 until 1972. He retired from Yale in 1977 and lectured at the University of California until 1982. Psychiatrist, educator and administrator, he is considered one of the founders of social psychiatry. He also had a special participation in ethical questions, presiding over the Commission for the Study of Ethical Problems in Medicine and the Biomedical and Behavioral Research, in 1979. He died in 2004 at the age of 93.

4

The data that had an impact and headlined the first page of the

New York Times refer to information concerning 1,660 respondents from a population of approximately 110 thousand adults between the ages of 20 and 59, who had their mental situation classified as follows: Well, 18.5%; Mild Symptom Formation, 36.3%; Moderate Symptom Formation, 21.8%; and 23.4% with problems, labeled Marked, Severe and Incapacitating.

5

It is calculated that over one million men were rejected for military service due to neurological and psychological problems and some 850 thousand soldiers were hospitalized for mental problems during the war. The Army's team of medical psychiatrists, which in 1940 totaled 25 professionals, during the war rose to 2,400.

6

Hollingshead (1971) relates in detail the evolution of his interest in the study of the structure of contemporary societies, initiated in the "summer of 1931" when he traveled to British Columbia; the empirical studies between 1933 and 1942; the first research in New Haven in 1947; and, in the 1950s, the work in collaboration with Redlich, whose initial results were presented in 1952 to the American Sociological Association and published the following year. He explains that, initially, there were three factors in construction of the ISP; place of residence in the community, the head of the family's occupation and the years of schooling completed by the head of the family. He does not rule out that the ISP was important in the New Haven research, but he advises that the research on the area of residence required a lot of work and was expensive and, reanalyzing the data of the investigation, he concluded: "residential scale contributed very little to the determination of estimated class position" (p.565). Hollingshead continues: "Thus, the Two Factor Index of Social Position came into being. It

was and

is a spin-off from the study of the social structure in the New Haven community" (p.565; author's emphasis).

Publication Dates

• Publication in this collection
  13 Apr 2010
• Date of issue
  Mar 2010

History

• Accepted
  Dec 2009
• Received
  Mar 2009