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UBC Theses and Dissertations

Medicalizing deviance in the community of elderly : a new psychiatric entreprise Smith, André Philippe 1989

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MEDICALIZING DEVIANCE IN THE COMMUNITY OF ELDERLY: A NEW PSYCHIATRIC ENTREPRISE by A n d r e P h i l i p p e S m i t h B.R.E. The U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1984 B.S.W. The U n i v e r s i t y o f B r i t i s h C o l u m b i a , 1987 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER ' OF SOCIAL WORK i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l o f S o c i a l Work) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA O c t o b e r 1989 ® A n d r e P h i l i p p e S m i t h , 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT This study i s about the process by which deviance i s transformed into the medical category of medical i l l n e s s i n the e l d e r l y l i v i n g i n the community. Mental i l l n e s s i s considered here as a form of deviance i n the s o c i o l o g i c a l sense of term as i t involves departure from s o c i a l l y expected r a t i o n a l behavior. More s p e c i f i c a l l y , the study demonstrates by using a p a r t i c i p a n t observation approach how p s y c h i a t r i c professionals i n a community mental healthy team have created a new market for the d i s t r i b u t i o n of t h e i r s p e c i a l i z e d g e r i a t r i c services by establishing a network of both lay people and professionals who are trained to r e f e r to the team e l d e r l y people whom they i d e n t i f y as mentally i l l . However, much of the i l l n e s s i n the study's sample of referred e l d e r l y related more to the 'problems of l i v i n g ' they experienced i n struggling with the generally poor s o c i a l conditions they were faced with, including forced retirement, inadequate income and housing, and physical i l l n e s s . In some instances, such problems also stemmed from t h e i r differences i n l i f e s t y l e , personal needs, and b e l i e f s with the s t a f f i n the i n s t i t u t i o n s caring for them. By acknowledging the e l d e r l y ' s 'problems of l i v i n g 1 as p s y c h i a t r i c disorders, the community mental health team e f f e c t i v e l y i s o l a t e d them from t h e i r s o c i a l and p o l i t i c a l context by making them into i n d i v i d u a l problems. This approach become a move towards 'blaming the v i c t i m 1 , hence i i i ignoring the p o l i t i c a l (rather than therapeutic) interventions needed to improve the conditions contributing to the presence of such problems. F i n a l l y , the study shows that community p s y c h i a t r i c professionals within the team tend to medicalize deviance as a response to the constraints imposed on them by t h e i r agency, which functions within a bio-medical framework i n d e l i v e r i n g mental health services to the community. i v TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENT .... i v LIST OF TABLES v i ACKNOWLEDGEMENT . v i i INTRODUCTION 1 CHAPTER ONE - DEVIANCE AND ITS CHARACTERISTICS 4 Defining Deviance 4 Chara c t e r i s t i c s of Deviance 7 Soc i a l Class, Medicalization and the The Growth of Psychiatry 16 Medicalization, The El d e r l y and Psychiatry .... 24 CHAPTER TWO - METHODOLOGY 28 Theoretical Framework 28 Hypotheses 3 0 Research Settings 31 Methods of Data C o l l e c t i o n 34 F i e l d Strategy 38 Methodological Considerations 43 CHAPTER THREE - RESEARCH SETTINGS AND DESCRIPTION OF SAMPLES 50 Research Settings 50 Sampling Frame 56 Sampling Procedure 59 Description of Cases 65 V CHAPTER FOUR - IDENTIFYING DEVIANCE IN THE COMMUNITY: THE ROLE OF REFERRING AGENTS 72 The Referring Agents: Who are They and Why do They Refer to the Community Mental Health Team? 72 The Nature of the Deviance Referred by Agents 79 CHAPTER FIVE - MEDICALIZING DEVIANCE: THE ROLE OF THE COMMUNITY MENTAL HEALTH TEAM 106 Promoting G e r i a t r i c Mental Health Services i n the Community: The Role of the G e r i a t r i c S p e c i a l i s t 107 Medicalization: Transforming Deviance into Mental I l l n e s s 115 Soci a l Control and Medicalization: The Role of the G e r i a t r i c S p e c i a l i s t Revisited .... 128 CONCLUSION 13 5 BIBLIOGRAPHY 141 v i LIST OF TABLES Page Table I 1986 Census Tract Data . . 57 Table II Population Charac t e r i s t i c s -Referral Form Sample 62 Table III Comparison of Population C h a r a c t e r i s t i c s - Census Tract and Referral Form Sample 63 Table IV Source of Referral by Referring agent and Service Agency from Review of 1987 Referral Forms Sample 74 Table V Breakdown of Referring Agents by Occupation from Review of 1987 Referral Forms Sample I l l v i i To my advisors, Nancy Waxier-Morrison and Kathryn McCannell, and to the elderly who have made this thesis possible by sharing with me their fight for freedom and dignity. 1 INTRODUCTION Deviance i s as part of society as i s conformity. Every human group throughout h i s t o r y regardless of i t s cohesiveness had to respond to such problems as violence, r i o t s , sexual misconduct, or b i z a r r e behavior. Understanding how a given society deals with i t s deviant members involves the study of norms. They provide the baseline against which deviation i s defined, sanctioned, and corrected. H i s t o r i c a l l y , deviant behaviours which were once defined as immoral, s i n f u l , or criminal have now been given medical meanings. Thus was created mental i l l n e s s . This medicalization of deviance has not occurred by i t s e l f through the natural evolution of society. Rather i t i s the r e s u l t of the working of s p e c i f i c people operating under c e r t a i n p o l i t i c a l and economic constraints who sought to explain and treat deviance as departure from normal brain function. Thus came about psychiatry. Psychiatry's stronghold has t r a d i t i o n a l l y been the asylum and the h o s p i t a l . However, i n the 1960's i n the United States Community Mental Health Centres were developed i n an attempt to turn p s y c h i a t r i c knowledge and techniques to community problems. Gerald Caplan's (1964) P r i n c i p l e s of  Preventive Psychiatry became the b i b l e of the movement which advocated the prevention of mental i l l n e s s through early i d e n t i f i c a t i o n and treatment of p s y c h i a t r i c disorders Caplan recommended t h a t p s y c h i a t r i s t s and o t h e r m e n t a l h e a l t h p r o f e s s i o n a l s s h o u l d a n t i c i p a t e c r i s i s and i n t e r v e n e t o h e l p p e o p l e c o p e w i t h s t r e s s f u l e v e n t s i n a v a r i e t y o f s e t t i n g s s u c h a s s c h o o l s , p r e - n a t a l c l i n i c s , d i v o r c e c o u r t s , i n an a t t e m p t t o c r e a t e a m e n t a l l y h e a l t h y s o c i a l e n v i r o n m e n t . However, i n b r e a k i n g away f r o m t h e h o s p i t a l , community p s y c h i a t r y n e v e r r e l i n q u i s h e d t h e m e d i c a l model o f m e n t a l i l l n e s s . P a t i e n t s were s t i l l c o n s i d e r e d t o be s u f f e r i n g f r o m d i s e a s e s o f t h e mind. I n f a c t , community p s y c h i a t r y e x p a n d e d t h e m e d i c a l model o f human p r o b l e m s by w i d e n i n g i t s d e f i n i t i o n o f m e n t a l i l l n e s s i n i t s e f f o r t s t o s t r e n g t h e n i t s j u r i s d i c t i o n o v e r d e v i a n c e . The e l d e r l y h a v e become a p r i m e t a r g e t f o r community p s y c h i a t r y ' s o n g o i n g s e a r c h f o r t h o s e i n n e e d o f p s y c h i a t r i c s e r v i c e s . T h e i r g e n e r a l l y p o w e r l e s s s t a t u s w i t h i n s o c i e t y makes them more l i k e l y t o e x p e r i e n c e t h e p r o b l e m s o f l i v i n g r e d e f i n e d as i l l n e s s by p s y c h i a t r i c e n t r e p r e n e u r s . T h i s s t u d y i s a b o u t t h e p r o c e s s o f m e d i c a l i z i n g d e v i a n c e i n t h e e l d e r l y . I t d e m o n s t r a t e s how p s y c h i a t r i c p r o f e s s i o n a l s i n a community m e n t a l h e a l t h team have opened new m a r k e t s f o r t h e d e l i v e r y o f s p e c i a l i z e d g e r i a t r i c s e r v i c e s by c r e a t i n g a n e t w o r k o f community a g e n t s i n v a r i o u s i n s t i t u t i o n s who a r e t r a i n e d t o r e f e r e l d e r l y t h e y i d e n t i f y a s m e n t a l l y d i s t u r b e d . However, t h e i l l n e s s t h e s e a g e n t s r e f e r h a s more t o do w i t h human p r o b l e m s and c o n f l i c t s t h a n w i t h b r a i n p a t h o l o g y . T h e r e f o r e , i n t h e c o u r s e o f t r e a t i n g t h o s e p r o b l e m s , t h e community m e n t a l 3 h e a l t h team a c t s a s an a g e n t o f s o c i a l c o n t r o l f o r t h o s e i n s t i t u t i o n s . More i m p o r t a n t l y , t h i s s t u d y i l l u s t r a t e s t h e s t r u g g l e o f t h e e l d e r l y a s a new s o c i a l c l a s s a r i s i n g f r o m t h e r e q u i r e m e n t s o f a c a p i t a l i s t economy w h i c h h a s made n e c e s s a r y t h e n e e d f o r m a n d a t o r y r e t i r e m e n t . The i n d i v i d u a l i z a t i o n o f t h e p r o b l e m s f a c e d by t h i s c l a s s i n t o m e d i c a l e n t i t i e s o n l y s e r v e s t o blame t h e v i c t i m and d i v e r t a t t e n t i o n f r o m t h e r e a l p o l i t i c a l i s s u e s r e s p o n s i b l e f o r d e v i a n c e i n t h e f i r s t p l a c e . F i n a l l y , t h i s s t u d y a l s o r a i s e s q u e s t i o n s a b o u t t h e r o l e o f t h e s o c i a l work p r o f e s s i o n a s a c o n t r i b u t o r t o t h e c o n t r o l o f d e v i a n c e w i t h i n s o c i e t y . S o c i a l c h a n g e s c a n be made more l i k e l y i f s o c i a l w o r k e r s a s a g r o u p i n v o l v e t h e m s e l v e s i n t h e p o l i t i c a l s t r u g g l e o f t h e w o r k i n g c l a s s r a t h e r t h a n i n t h e m e d i c a l i z a t i o n o f i t s demands. 4 CHAPTER ONE DEVIANCE AND ITS CHARACTERISTICS I n r e v i e w i n g t h e l i t e r a t u r e on d e v i a n c e , I have r e t a i n e d a number o f d e f i n i t i o n s and c h a r a c t e r i s t i c s w h i c h a l l p o i n t t o a c e n t r a l c o n c e p t : t h a t d e v i a n c e a l t h o u g h a u n i v e r s a l phenomenon, i s s o c i a l l y r e l a t i v e i n i t s d e f i n i t i o n a n d s a n c t i o n i n g . More s p e c i f i c a l l y , d e v i a n c e i s u s u a l l y i d e n t i f i e d and c o n t r o l l e d a s s u c h i n l e s s p o w e r f u l members o f a g i v e n s o c i e t y by i t s d o m i n a n t c l a s s t o p r e s e r v e an e c o n o m i c and s o c i a l o r d e r t h e y b e n e f i t f r o m . T h i s c h a p t e r w i l l a l s o i l l u s t r a t e t h e c o n c e p t o f d e v i a n c e t h r o u g h e x a mples t a k e n f r o m t h e s o c i o l o g i c a l l i t e r a t u r e on m e n t a l i l l n e s s . More s p e c i f i c a l l y , I w i l l show how d e v i a n c e h a s b e n e f i t e d p s y c h i a t r i s t s i n t h e i r e f f o r t s t o d e f i n e and s a n c t i o n i t a s a b i o l o g i c a l d i s e a s e ; DEFINING DEVIANCE The s t u d y o f d e v i a n c e h a s a t t r a c t e d t h e a t t e n t i o n o f s o c i o l o g i s t s s i n c e t h e t u r n o f t h e c e n t u r y . T h i s i n t e r e s t h a s g e n e r a t e d numerous a t t e m p t s a t d e f i n i n g and u n d e r s t a n d i n g d e v i a n c e and e x p l a i n i n g i t s c a u s e s . The d e f i n i t i o n s o f f e r e d by s e v e r a l s c h o l a r s h a v e much i n common i n t h e s e n s e t h a t d e v i a n c e i s u s u a l l y s e e n as d o i n g o r b e i n g t h a t w h i c h i s s o c i a l l y d i s a p p r o v e d , a l t h o u g h t h e y d i f f e r i n t h e i r e m p h a s i s on t h e b e h a v i o r s w h i c h e l i c i t s u c h 5 d i s a p p r o v a l . More s p e c i f i c a l l y , t h e y d e s c r i b e d e v i a n c e as norm o r r u l e v i o l a t i o n s w h i c h a r e n e g a t i v e l y p e r c e i v e d by t h e s o c i e t y i n w h i c h t h e y t a k e p l a c e . F o r example, D i n i t z , Dynes and C l a r k (1969) a f f i r m t h a t : R e g a r d l e s s o f t h e s p e c i f i c c o n t e n t o f b e h a v i o r , t h e e s s e n t i a l n a t u r e o f d e v i a n c e l i e s i n t h e d e p a r t u r e o f c e r t a i n t y p e s o f b e h a v i o r f r o m t h e norms o f a p a r t i c u l a r s o c i e t y a t a p a r t i c u l a r t i m e . (p. 4) A l o n g t h e same l i n e s , C l i n a r d (1968) d e s c r i b e d e v i a n t b e h a v i o r a s : E s s e n t i a l l y a v i o l a t i o n o f c e r t a i n t y p e s o f g r o u p norms; a d e v i a n t a c t i s b e h a v i o r w h i c h i s p r o s c r i b e d i n a c e r t a i n way. . . . O n l y t h o s e d e v i a t i o n s i n w h i c h b e h a v i o r i s i n a d i s a p p r o v e d d i r e c t i o n and o f s u f f i c i e n t d e g r e e t o e x c e e d t h e t o l e r a n c e l i m i t o f t h e community c o n s t i t u t e d e v i a n t b e h a v i o r (p. 2 8 ) . M a t z a (1969) r e l y i n g on a d i c t i o n a r y d e f i n i t i o n , w r i t e s i n a c o n c i s e and s i m p l e manner t h a t " t o d e v i a t e i s t o s t r a y a s f r o m a p a t h o r s t a n d a r d " (p. 10) . Some a u t h o r s h a v e c h o s e n t o s t u d y d e v i a n c e by p u t t i n g t h e e m p h a s i s on how s u c h d e v i a n c e i s so d e f i n e d by s o c i e t y . T h e s e d e f i n i t i o n s s h i f t a t t e n t i o n f r o m d e v i a n c e as a s p e c i f i c p a t t e r n o f b e h a v i o r t o d e v i a n c e as s o c i a l d e f i n i t i o n o r l a b e l t h a t i n d i v i d u a l s u s e t o e x p l a i n t h e b e h a v i o r o f o t h e r s . B e c k e r ( 1 9 6 3 ) , f o r example, d e s c r i b e s t h e d e v i a n t as "one t o whom t h a t l a b e l h a s s u c c e s s f u l l y been a p p l i e d ; d e v i a n t b e h a v i o r i s b e h a v i o r t h a t p e o p l e so l a b e l " (p. 9 ) . B e c k e r h e r e seems t o r e f e r t o t h e f a c t t h a t w i t h i n a g i v e n s o c i e t y t h e r e a r e some p e o p l e o r g r o u p s who h a v e o r 6 t a k e t h e a u t h o r i t y t o l a b e l o t h e r s d e v i a n t . T h i s s u g g e s t s t h a t d e v i a n c e i s a r e l a t i v e s t a t u s t h a t c a n be r e d e f i n e d u n d e r c h a n g i n g s o c i e t a l c o n d i t i o n s by s i g n i f i c a n t members o f a s o c i e t y a s o p p o s e d t o an i n h e r e n t q u a l i t y o f t h e p e r s o n who c a r r i e s t h e l a b e l . T h i s c o n c e p t i s a l s o e c h o e d by E r i c k s o n (1966) who d e c l a r e s t h a t : D e v i a n c e i s n o t a p r o p e r t y i n h e r e n t i n any p a r t i c u l a r k i n d o f b e h a v i o r ; i t i s a p r o p e r t y c o n f e r r e d upon t h a t b e h a v i o r by t h e p e o p l e who come i n t o d i r e c t o r i n d i r e c t c o n t a c t w i t h i t . (p. 6) So i n s h o r t , i t i s n o t t h e a c t b u t t h e d e f i n i t i o n t h a t makes someone d e v i a n t and h e n c e one c o u l d s u r m i s e t h a t t h e r e a r e no u n i v e r s a l f o r m s o f d e v i a n c e b u t o n l y s o c i a l l y c o n s t r u c t e d o n e s . T h i s c o n c e p t o f d e v i a n c e i s f u r t h e r r e f i n e d by S c h u r (1971) who c r e a t e d a d e f i n i t i o n t h a t i n c l u d e s s o c i a l r e a c t i o n t o i n d i v i d u a l s who a r e s u f f e r i n g f r o m a d i s a b i l i t y o r i l l n e s s , e v e n t h o u g h t h e l a t t e r may h a v e v i o l a t e d no e x p l i c i t r u l e o r norm. He s u g g e s t s t h a t : Human b e h a v i o r i s d e v i a n t t o t h e e x t e n t t h a t i t comes t o be v i e w e d a s i n v o l v i n g a p e r s o n a l l y d i s c r e d i t a b l e d e p a r t u r e f r o m a g r o u p ' s n o r m a t i v e e x p e c t a t i o n s , and i t e l i c i t s i n t e r p e r s o n a l o r c o l l e c t i v e r e a c t i o n s t h a t s e r v e t o i s o l a t e , t r e a t , c o r r e c t , o r p u n i s h i n d i v i d u a l s e n g a g e d i n s u c h b e h a v i o r , (p. 74) The d e f i n i t i o n a c c o u n t s f o r an i m p o r t a n t a s p e c t o f d e v i a n c e : t h a t o f a b n o r m a l i t y and p a t h o l o g y as d e v i a n c e . W i t h i n t h i s framework, m e n t a l i l l n e s s i s v i e w e d as a f o r m o f d e v i a n t b e h a v i o r l i k e c r i m e , j u v e n i l e d e l i n q u e n c y , 7 and d r u g a d d i c t i o n . U n l i k e p s y c h o l o g i s t s o r p s y c h i a t r i s t s , who a r e p r i m a r i l y d e a l i n g w i t h t h e s t u d y and t h e t r e a t m e n t o f i n d i v i d u a l c a s e s o f m e n t a l i l l n e s s , s o c i o l o g i s t s t e n d t o a p p r o a c h p s y c h i a t r i c d i s o r d e r s i n t e r m s o f g r o u p o r l a r g e r s o c i e t a l p r o c e s s e s t h a t i n f l u e n c e t h e c o n d u c t o f i n d i v i d u a l b e h a v i o r . M e n t a l i l l n e s s i s p e r c e i v e d as s i g n i f i c a n t d e v i a t i o n f r o m t h a t w h i c h i s c o n s i d e r e d o r e x p e c t e d t o be n o r m a l c o n d u c t i n a g i v e n g r o u p o r s o c i e t y . CHARACTERISTICS OF DEVIANCE F o r t h e p u r p o s e o f t h i s s t u d y I have r e t a i n e d t h r e e c h a r a c t e r i s t i c s o f d e v i a n c e a s i d e n t i f i e d by C o n r a d ( 1 9 8 0 ) . T h e s e a r e : d e v i a n c e i s s o c i a l l y d e f i n e d ; s o c i a l g r o u p s make r u l e s and e n f o r c e t h e i r d e f i n i t i o n s o f d e v i a n c e on t h e i r members t h r o u g h j u d g ement and s o c i a l s a n c t i o n s ; and d e f i n i n g and s a n c t i o n i n g d e v i a n c e i s f o r t h e p u r p o s e o f one g r o u p e s t a b l i s h i n g d o m i n a n c e o v e r a n o t h e r t h r o u g h s o c i a l c o n t r o l . (1) D e v i a n c e i s S o c i a l l y D e f i n e d E v e r y s o c i e t y r e g a r d l e s s o f t i m e o r p l a c e h a s d e f i n e d some o f i t s members as m e n t a l l y i l l . Y e t d i f f e r e n t s o c i e t i e s c o n s i d e r d i f f e r e n t a c t i v i t i e s a s m e n t a l i l l n e s s . T h e r e a r e few a c t s , i f any, t h a t a r e s e e n a s d e v i a n t i n a l l s o c i e t i e s and d e a l t w i t h i n t h e same manner. F o r example, c e r t a i n f o r m s o f h o m o s e x u a l i t y i n v o l v i n g m a l e a d u l t s and y o u n g e r b o y s were a c c e p t a b l e among t h e c u l t u r a l e l i t e i n 8 c l a s s i c a l G r e e c e , b u t i n A m e r i c a t o d a y s u c h b e h a v i o r i s r e p o r t e d i n t h e DSM I I I - R ( D i a g n o s t i c a l S t a t i s t i c a l M anual, R e v i s e d , 1987) a s a p s y c h i a t r i c d i s o r d e r u n d e r t h e name p e d o p h y l i a . S u i c i d e i s a n o t h e r example o f a b e h a v i o r c o n s i d e r e d d e v i a n t and u n g o d l y i n most C h r i s t i a n c u l t u r e s and y e t i n J a p a n , s u c h b e h a v i o r i s c o n s i d e r e d an h o n o r a b l e a c t ( C o n r a d , 1 9 8 0 ) . T h e s e e x a m p l e s s e r v e t o i l l u s t r a t e t h e n o t i o n o f what R u t h B e n e d i c t (1934) c a l l s c u l t u r a l r e l a t i v i t y , m e a n i n g t h a t e a c h s o c i e t y s h o u l d be v i e w e d by i t s own c o n c e p t i o n s and s t a n d a r d s o f b e h a v i o r s when l o o k i n g a t how i t d e f i n e s d e v i a n c e . T h i s n o t i o n o f r e l a t i v i t y c a n a l s o be a p p l i e d t o g r o u p s o r s u b c u l t u r e s w i t h i n a g i v e n s o c i e t y . What i s t o l e r a t e d by one g r o u p o f p e o p l e ( e . g . , s t r e e t p e o p l e ) may n o t be a c c e p t a b l e t o a n o t h e r g r o u p ( e . g . , u p p e r c l a s s ) and h e n c e j u d g e d t o be d e v i a n t by t h e l a t e r . T h i s i m p l i e s t h e n o t i o n t h a t d e v i a n c e d o e s n o t e x i s t by i t s e l f o b j e c t i v e l y r e g a r d l e s s o f t h e a c t , b e h a v i o r o r s t a t u s . As C o n r a d (1980) p o i n t s o u t , " d e v i a n c e i s a s o c i a l l y a t t r i b u t e d c o n d i t i o n , and ' d e v i a n t ' i s an a s c r i b e d s t a t u s " (p. 6 ) . T h e r e f o r e , w i t h i n t h i s framework, m e n t a l i l l n e s s i s n o t t h e c h a r a c t e r i s t i c o f s p e c i f i c s e t s o f b e h a v i o r s b u t r a t h e r e x i s t s a s a c a t e g o r y o f b e h a v i o r s t h a t h a v e b e e n d e f i n e d a s s u c h by s i g n i f i c a n t a c t o r s w i t h i n o u r s o c i e t y . S c h e f f (1975) i l l u s t r a t e s t h i s p o i n t by s a y i n g t h a t : The c o n c e p t s o f m e n t a l i l l n e s s i n g e n e r a l - and s c h i z o p h r e n i a i n p a r t i c u l a r - a r e n o t n e u t r a l , v a l u e -f r e e , s c i e n t i f i c a l l y p r e c i s e t e r m s b u t a r e , f o r t h e 9 most p a r t t h e l e a d i n g edge o f an i d e o l o g y embedded i n t h e h i s t o r i c a l and c u l t u r a l p r e s e n t o f t h e w h i t e m i d d l e c l a s s o f w e s t e r n s o c i e t i e s . (p. 7) By c o n s i d e r i n g m e n t a l i l l n e s s a s a s o c i a l l y d e f i n e d phenomenon, i t c a n be a r g u e d t h a t s u c h d e f i n i t i o n c a n change a c c o r d i n g t o w h i c h i n d i v i d u a l s , g r o u p s o r s o c i e t y e v a l u a t e s and d e f i n e s d e v i a n c e and f o r what p u r p o s e . R osenhan (1973) d e m o n s t r a t e d how r e l a t i v e and i n a c u r a t e t h e p r o c e s s o f i d e n t i f y i n g m e n t a l i l l n e s s c a n be i n a s t u d y where e i g h t e m i n e n t l y s a n e p e o p l e g a i n e d a c c e s s t o v a r i o u s p s y c h i a t r i c h o s p i t a l s a c r o s s t h e n a t i o n a s p s e u d o p a t i e n t s . T h e y were t h r e e p s y c h o l o g i s t s , one p s y c h o l o g y g r a d u a t e s t u d e n t , a p e d i a t r i c i a n , a p s y c h i a t r i s t , a p a i n t e r , and a h o u s e w i f e . The p s e u d o p a t i e n t s g a i n e d a d m i t t a n c e t o t h e h o s p i t a l s by c o m p l a i n i n g t h a t t h e y h a d b e e n h e a r i n g v o i c e s o f u n c l e a r c o n t e n t , e x c e p t t h a t t h e y a p p e a r e d t o s a y "empty," " h o l l o w , " and " t h u d . " Beyond a l l e g i n g t h e symptoms and f a l s i f y i n g name, v o c a t i o n , and employment, no f u r t h e r a l t e r a t i o n s o f p e r s o n , h i s t o r y , o r c i r c u m s t a n c e s were made. Upon t h e i r a d m i s s i o n t o t h e v a r i o u s h o s p i t a l s , t h e p s e u d o p a t i e n t s resumed t h e i r n o r m a l s e l f and s t o p p e d s i m u l a t i n g any symptoms o f m e n t a l i l l n e s s . The o b j e c t o f t h e s t u d y was t o s e e i f t h e s a n i t y o f t h e p s e u d o p a t i e n t s c o u l d be d e t e c t e d amid t h e i n s a n i t y o f t h e i n s t i t u t i o n a l s e t t i n g . I t was n o t . A l t h o u g h t h e y b e h a v e d on t h e wards a s t h e y d i d o r d i n a r i l y , o f t e n p u b l i c l y t a k i n g n o t e s f o r t h e s t u d y , none o f them was d i s c o v e r e d . I n f a c t , t h e p s e u d o p a t i e n t s were h o s p i t a l i z e d b e t w e e n 7 t o 52 d a y s , 10 w i t h an a v e r a g e o f 19 d a y s and e a c h g o t d i s c h a r g e d w i t h a d i a g n o s i s o f s c h i z o p h r e n i a i n r e m i s s i o n . I n t e r e s t i n g l y enough, Rosenhan ( i b i d ) c o n d u c t e d a n o t h e r e x p e r i m e n t t o s e e i f t h e t e n d e n c y o f d i a g n o s i n g t h e sane i n s a n e c o u l d be r e v e r s e d . I t o c c u r r e d i n a r e s e a r c h and t e a c h i n g h o s p i t a l whose s t a f f was i n f o r m e d t h a t i n a t h r e e month p e r i o d , one o r more p s e u d o p a t i e n t s w o u l d a t t e m p t t o g a i n a d m i s s i o n i n t o t h e i r f a c i l i t y . E a c h s t a f f p e r s o n was a s k e d t o r a t e e a c h p a t i e n t a c c o r d i n g t o t h e p o s s i b i l i t y o f him o r h e r b e i n g a " s a n e " p e r s o n . R a t i n g s on 193 p a t i e n t s were o b t a i n e d and f o r t y - o n e o f them were a l l e g e d l y r a t e d a s p s e u d o p a t i e n t s by a t l e a s t one s t a f f member and t w e n t y - t h r e e o f t h o s e f o r t y were r a t e d a s s u c h by p s y c h i a t r i s t s . The r e a l i t y o f t h e e x p e r i m e n t was t h a t no p s e u d o p a t i e n t a t t e m p t e d t o g a i n a c c e s s t o t h e h o s p i t a l . T h e s e two e x p e r i m e n t s l e a d t h e a u t h o r t o c o n c l u d e t h a t " i t i s c l e a r t h a t we c a n n o t d i s t i n g u i s h t h e s a n e f r o m t h e i n s a n e i n p s y c h i a t r i c h o s p i t a l s " (p. 71) and t h e r e f o r e p s y c h i a t r i c d i a g n o s e s may t e l l u s more a b o u t t h e d i a g n o s t i c i a n s d e f i n i n g t h e i l l n e s s t h a n a b o u t t h e p a t i e n t s and t h e i r p r o b l e m s . (2) S o c i a l g r o u p s make r u l e s and e n f o r c e t h e i r d e f i n i t i o n s  o f d e v i a n c e t h r o u g h j u d g e m e n t s and s o c i a l s a n c t i o n s T h i s s t a t e m e n t r e f e r s t o t h e mechanism by w h i c h d e v i a n c e i s c r e a t e d . B e c k e r (1964) d e c l a r e s t h a t " s o c i a l g r o u p s c r e a t e d e v i a n c e by ma k i n g t h e r u l e s whose i n f r a c t i o n c o n s t i t u t e d d e v i a n c e , and a p p l y i n g t h o s e r u l e s t o p a r t i c u l a r 11 p e o p l e and l a b e l i n g them a s [ d e v i a n t s ] " (p. 4 ) . I n t e r m s o f m e n t a l i l l n e s s , one c a n c o n s i d e r t h e D i a g n o s t i c S t a t i s t i c a l  M a n u a l I I I - R o f t h e A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n (1987) a s a s e t r u l e s w h i c h d e f i n e s what i s a b n o r m a l b e h a v i o r and w h i c h p s y c h i a t r i s t s , who a r e s a n c t i o n e d b y s o c i e t y t o a p p l y t h e s e r u l e s , u s e t o g u i d e t h e i r j u d g e m e n t i n d e t e r m i n i n g who i s o r i s n o t d e v i a n t . (3) D e f i n i n g and S a n c t i o n i n g D e v i a n c e I n v o l v e s Power H i s t o r i c a l l y , t h e more p o w e r f u l members w i t h i n a s o c i e t y h a v e b e e n e s t a b l i s h i n g s t a n d a r d s o f c o n d u c t f o r t h e l e s s p o w e r f u l o n e s . Power i s u s u a l l y d e t e r m i n e d i n t h e s o c i o l o g i c a l l i t e r a t u r e i n t e r m s o f k e y s o c i o - d e m o g r a p h i c c h a r a c t e r i s t i c s s u c h a s s o c i a l c l a s s , r a c e , s e x , and m a r i t a l s t a t u s . M o s t s t u d i e s on power h a v e u s e d e p i d e m i o l o g i c a l methods i n d e t e r m i n i n g t h e p r e v a l e n c e o r i n c i d e n c e o f m e n t a l i l l n e s s i n s o c i a l a g g r e g a t e s o r l a r g e g r o u p s o f p e o p l e . One o f t h e most c o n s i s t e n t f i n d i n g s i n t h i s a r e a h a s b e e n t h a t t h e p r e s e n c e o f m e n t a l symptoms i s i n v e r s e l y p r o p o r t i o n a l t o t h e l e v e l o f t h e s o c i a l c l a s s ( H o r w i t z , 1980) . I n o t h e r words, t h e l o w e s t s o c i a l c l a s s i n v a r i a b l y d i s p l a y s a g r e a t e r amount o f m e n t a l i l l n e s s t h a n t h e h i g h e s t s o c i a l c l a s s e s . One o f t h e most i m p o r t a n t s t u d i e s i n t h i s a r e a was u n d e r t a k e n by H o l l i n g h e a d and R e d l i c h (1958) i n New Haven, C o n n e c t i c u t . The a u t h o r s t h e n a t t e m p t e d t o c o l l e c t d a t a on a l l t r e a t e d c a s e s o f m e n t a l i l l n e s s i n New Haven, 12 C o n n e c t i c u t . T h ey s u r v e y e d a l l t h e c l i n i c s , h o s p i t a l s , and p r i v a t e p r a c t i t i o n e r s i n t h e n o r t h e a s t e r n U n i t e d S t a t e s t h a t m i g h t h a v e b e e n u s e d by New Haven r e s i d e n t s . E a c h p a t i e n t was c l a s s i f i e d a c c o r d i n g t o t h e i r membership i n one o f f i v e s o c i a l c l a s s e s : c l a s s I b e i n g t h e u p p e r c l a s s ; c l a s s I I , t h e u p p e r m i d d l e c l a s s ; c l a s s I I I , t h e m i d d l e c l a s s ; c l a s s IV, t h e w o r k i n g c l a s s ; and f i n a l l y , c l a s s V, t h e l o w e r c l a s s . The a u t h o r s f o u n d t h a t t h e l o w e r t h e c l a s s , t h e g r e a t e r t h e t e n d e n c y i s t o w a r d p s y c h o t i c p r o b l e m s s u c h as s c h i z o p h r e n i a ; and t h e h i g h e r t h e c l a s s , t h e more p r e v a l e n t t h e t e n d e n c y was t o w a r d m e n t a l i l l n e s s o f l e s s e r g r a v i t y s u c h a s n e u r o s i s . I n t e r e s t i n g l y enough, t h e y a l s o f o u n d t h a t i n d i v i d u a l s f r o m t h e l o w e s t s o c i a l c l a s s , t h e one w i t h t h e h i g h e s t p r e v a l e n c e o f m e n t a l i l l n e s s , were i n c o n t r a s t much l e s s i n c l i n e d t o a t t r i b u t e p e r s o n a l p r o b l e m s t o m e n t a l d i s o r d e r o r t o l a b e l someone a s m e n t a l l y i l l . And y e t , t h e y were most o f t e n i d e n t i f i e d as n e e d i n g p s y c h i a t r i c c a r e and c o n s e q u e n t l y r e f e r r e d t o t h e a p p r o p r i a t e a g e n c i e s ( e . g . , h o s p i t a l s , a s y l u m s ) by ' s o c i a l c o n t r o l ' p r o f e s s i o n a l s s u c h a s t h e p o l i c e o r w o r k e r s f r o m t h e s o c i a l w e l f a r e a g e n c i e s . One f l a w o f t h i s s t u d y however i s t h e s e v e r e l y l i m i t e d g e n e r a l i z a b i l i t y o f i t s f i n d i n g s t o t h e g e n e r a l p o p u l a t i o n n o t r e c e i v i n g p s y c h i a t r i c t r e a t m e n t . I t s s a m ple i n c l u d e d o n l y t h o s e i n d i v i d u a l s who were a l r e a d y i d e n t i f i e d a s m e n t a l p a t i e n t s and r e c e i v i n g p s y c h i a t r i c s e r v i c e s . I t f a i l s t o a c c o u n t f o r a ' t r u e ' p r e v a l e n c e o f m e n t a l i l l n e s s by n o t i n c l u d i n g many p e o p l e who a r e ' m e n t a l l y i l l ' a t l a r g e i n t h e 13 community b u t n o t r e c e i v i n g p s y c h i a t r i c c a r e . N e v e r t h e l e s s , i t c l e a r l y showed t h a t t h e p o o r were more l i k e l y t o be i n s t i t u t i o n a l i z e d as m e n t a l p a t i e n t s t h a n w e a l t h i e r members o f s o c i e t y , and t h a t s u c h a p r o c e s s was most l i k e l y t o be i n i t i a t e d by a t h i r d p a r t y s u c h a s t h e p o l i c e o r s o c i a l w o r k e r s . S r o l e e t a l . (1962) i n t h e i r M idtown M a n h a t t a n s t u d y a d d r e s s e d t h i s p r o b l e m o f t r u e p r e v a l e n c e o f m e n t a l d i s o r d e r w h i c h H o l l i n g s h e a d and R e d l i c h f a i l e d t o look. a t . B e c a u s e t h e l a t t e r s t u d y l o o k e d s t r i c t l y a t t r e a t e d c a s e s o f m e n t a l i l l n e s s , t h e a u t h o r s d e c i d e d t o l o o k o n l y a t c a s e s o f u n t r e a t e d m e n t a l i l l n e s s i n t h e g e n e r a l p o p u l a t i o n . Some 1,660 i n d i v i d u a l s were i n t e r v i e w e d by a team o f p s y c h i a t r i s t s t o a s s e s s t h e i r p s y c h i a t r i c c o n d i t i o n . The r e s u l t s h e n c e o b t a i n e d b o r e g r e a t s i m i l a r i t i e s w i t h H o l l i n g s h e a d and R e d l i c h ' s (1958) s t u d y as t h e y c o r r o b o r a t e d p r e v i o u s f i n d i n g s t h a t more m e n t a l i l l n e s s was l o c a t e d i n t h e l o w e r s o c i a l c l a s s . S i m i l a r l y , a n o t h e r e p i d e m i o l o g i c a l s t u d y by L e i g h t o n and h i s a s s o c i a t e s (1968) i n d i c a t e d an e x t r e m e l y h i g h l e v e l o f t r u e p r e v a l e n c e o f m e n t a l d i s o r d e r i n a random sample o f 1,3 03 r e s p o n d e n t s i n a r u r a l c o u n t y i n Nova S c o t i a . The r e s p o n d e n t s were r a t e d a s t o t h e i r p r o b a b i l i t y o f b e i n g d i a g n o s e d a s m e n t a l l y i l l by a team o f p s y c h i a t r i s t s a p p l y i n g t h e s t a n d a r d s f o u n d i n t h e DSM-II (APA, 1 9 68). P r e d i c t a b l y , t h e r e s u l t s o f t h e s t u d y i n d i c a t e d t h a t m e n t a l 14 d i s o r d e r was most p r e v a l e n t among i n d i v i d u a l s o f t h e l o w e s t s o c i o - e c o n o m i c g r o u p . A number o f e x p l a n a t i o n s h a v e b e e n a d v a n c e d t o a c c o u n t f o r t h e r e l a t i o n s h i p between l o w e r s o c i a l c l a s s and m e n t a l i l l n e s s . From t h e m e d i c a l p e r s p e c t i v e comes t h e g e n e t i c t h e o r y w h i c h s a y s t h a t members o f l o w e r s o c i o - e c o n o m i c g r o u p s a r e more p r e d i s p o s e d t o w a r d m e n t a l d i s o r d e r . T h i s t h e o r y r e m a i n s i n c o n c l u s i v e however a s numerous s t u d i e s have d e m o n s t r a t e d t h a t g e n e t i c f a c t o r s a l o n e a r e i n s u f f i c i e n t t o a c c o u n t f o r t h e f a c t t h a t d i s o r d e r s s u c h a s s c h i z o p h r e n i a a r e most p r e v a l e n t i n l o w e s t s o c i o - e c o n o m i c g r o u p s ( S h i e l d , H e s t o n , and G o t t e s m a n , 1 9 7 5 ) . A n o t h e r e x p l a n a t i o n b r o u g h t f o r w a r d by H a r k e y e t a l (1976) i s t h a t o f s o c i a l s e l e c t i o n w h i c h p r o p o s e s t h a t m e n t a l l y i l l and u n s t a b l e i n d i v i d u a l s t e n d t o p o o l o r d r i f t t o w a r d l e s s e r s o c i a l c l a s s e s w h e r e a s h e a l t h i e r i n d i v i d u a l on t h e o t h e r hand t e n d t o be u p w a r d l y m o b i l e and c o n g r e g a t e i n t h e u p p e r c l a s s . I n o t h e r words, m e n t a l d i s o r d e r h e r e i s c o n s i d e r e d a c o n t r i b u t o r t o s o c i a l c l a s s p o s i t i o n . However, i n r e v i e w i n g t h e w e i g h t o f t h e e v i d e n c e f o r s t u d i e s u s i n g a s o c i a l s e l e c t i o n m o d el, M e l v i n Kohn (1976) c o n c l u d e s t h a t a t l e a s t i n t h e c a s e o f s c h i z o p h r e n i a : I n d i v i d u a l s h a v e been no more downwardly m o b i l e ( i n f a c t , no l e s s u p w a r d l y m o b i l e ) t h a n o t h e r p e o p l e f r o m t h e same s o c i a l b a c k g r o u n d s , o r a t a minimum, t h a t t h e d e g r e e o f downward m o b i l i t y i s i n s u f f i c i e n t t o e x p l a i n t h e h i g h c o n c e n t r a t i o n o f s c h i z o p h r e n i a i n t h e l o w e s t s o c i o - e c o n o m i c s t r a t a . 15 So, t h e s o c i a l s e l e c t i o n p e r s p e c t i v e a p p e a r s t o be no more a d e q u a t e t h a n t h e g e n e t i c p r e d i s p o s i t i o n model i n a c c o u n t i n g f o r t h e g r e a t e r p r e s e n c e o f m e n t a l i l l n e s s i n l o w e r s o c i a l c l a s s e s . T h e r e f o r e t h e r e i s a n e e d f o r an a l t e r n a t i v e model t o e x p l a i n why t h e p o o r , t h e h e l p l e s s , t h e m a r g i n a l s (and t h e e l d e r l y c e r t a i n l y c a n be i n c l u d e d amongst t h e s e c a t e g o r i e s ) i n v a r i a b l y a r e d i a g n o s e d more f r e q u e n t l y w i t h i n s a n i t y . I n r e v i e w i n g t h e l i t e r a t u r e on s o c i a l c l a s s and m e n t a l i l l n e s s , H o r w i t z (1980) n o t e s t h a t : The r e c o g n i t i o n o f m e n t a l i l l n e s s v a r i e s d i r e c t l y w i t h t h e s o c i a l c l a s s o f t h e l a b e l e r . The h i g h e r t h e s o c i a l c l a s s s t a t u s o f t h e l a b e l e r , t h e more l i k e l y t h e y a r e t o r e c o g n i z e and l a b e l m e n t a l i l l n e s s . C o n v e r s e l y , as s o c i a l c l a s s d e c l i n e s , s o d o e s t h e l i k e l i h o o d t h a t o b s e r v e r s w i l l a p p l y l a b e l s o f m e n t a l i l l n e s s ( p . 6 4 ) . The a u t h o r adds however t h a t t h e s e s t u d i e s do n o t n e c e s s a r i l y i n d i c a t e t h a t t h e r e i s i n a c t u a l i t y more " t r u e " m e n t a l i l l n e s s i n t h e community b u t t h a t more l o w e r c l a s s i n d i v i d u a l s a r e d e f i n e d as m e n t a l l y i l l b y o t h e r s . I t becomes t h e n c r u c i a l t o l o o k a t who l a b e l s m e n t a l i l l n e s s and f o r what p u r p o s e . S i n c e t h e s t u d i e s on i n c i d e n c e s and p r e v a l e n c e o f p s y c h i a t r i c d i s o r d e r s i n t h e g e n e r a l p o p u l a t i o n e x c l u s i v e l y r e l y upon p s y c h i a t r i s t s ' s u b j e c t i v e j u d g e m e n t s i n i d e n t i f y i n g e i t h e r t h e p r e s e n c e o r a b s e n c e o f m e n t a l i l l n e s s one h a s t o l o o k a t a c a s e o f a p o w e r f u l s o c i a l g r o u p , p s y c h i a t r i s t s , d e f i n i n g and s a n c t i o n i n g d e v i a n c e i n a l e s s p o w e r f u l g r o u p , t h e l o w e r s o c i a l c l a s s . 16 L e t us e x p l o r e how t h i s power r e l a t i o n s h i p d e v e l o p e d i t s e l f h i s t o r i c a l l y . i SOCIAL CLASS. MEDICALIZATION & THE GROWTH OF PSYCHIATRY A l t h o u g h m e n t a l i l l n e s s a s a f o r m o f d e v i a n c e has a l w a y s b e e n r e c o g n i z e d i n one way o r a n o t h e r by s o c i e t y , i t was n o t u n t i l t h e 1 9 t h c e n t u r y t h a t m e d i c a l t h e o r i e s were a d v a n c e d t o e x p l a i n i n s a n i t y . P r e v i o u s l y , t h e i n s a n e were t r e a t e d s i m i l a r l y t o c r i m i n a l s o r sometimes t o l e r a t e d as v i l l a g e i d i o t s , o r b e l i e v e d t o be p o s s e s s e d by t h e d e v i l . The d e s t i t u t e , t h e p h y s i c a l l y d i s a b l e d , t h e m e n t a l l y r e t a r d e d and t h e i n s a n e were e s s e n t i a l l y c o n s i d e r e d t o be p a r t o f t h e same c a t e g o r y o f d e v i a n c e , and h o u s e d i n p r i s o n s o r p o o r h o u s e s . However, t h e r i s e o f t h e b i o l o g i c a l s c i e n c e s l e d a number o f p e o p l e t o t h e o r i z e t h a t m e n t a l d i s o r d e r was p r i m a r i l y a d i s e a s e b r o u g h t on by o r g a n i c c a u s e s . B e n j a m i n Rush (1745-1813) who i s w i d e l y c r e d i t e d t o be t h e f a t h e r o f A m e r i c a n p s y c h i a t r y , m a i n t a i n e d t h a t a b n o r m a l b e h a v i o r was d e r i v e d f r o m b r a i n d i s e a s e t h a t had i t s l o c u s i n t h e b r a i n ' s b l o o d v e s s e l s (Cockerham, 1981). G r a d u a l l y p s y c h i a t r i s t s s t a r t e d t o e m p h a s i z e s i m i l a r i d e a s a s p a r t o f t h e i r c l a i m t o p r o f e s s i o n a l l e g i t i m a c y i n m e d i c i n e and p r o p o s e d t h e u s e o f m e d i c a l t e c h n i q u e s i n t r e a t i n g m e n t a l i l l n e s s . I n t h e n e x t c e n t u r y , p s y c h i a t r y c o n t i n u e d t o grow as a p r o f e s s i o n v e r y much a l o n g t h e same l i n e s . E v e n t u a l l y , t h e 17 b i o c h e m i c a l a p p r o a c h e s s t a r t e d t o s u p e r s e d e t h e t h e o r i e s o f o r g a n i c b r a i n d i s e a s e i n e x p l a i n i n g m e n t a l d i s o r d e r . I n t h e 1950's, t h e d i s c o v e r y o f p s y c h o a c t i v e d r u g s f i n a l l y g ave p s y c h i a t r y an e f f e c t i v e m e d i c a l means o f t r e a t i n g m e n t a l i l l n e s s . C o n c o m i t a n t l y a l o n g w i t h a d v a n c e s i n s c i e n t i f i c d i s c o v e r i e s , t h e p r o f e s s i o n o f p s y c h i a t r y s t a r t e d t o g a i n s t a t u s and power as a m e d i c a l s p e c i a l t y . From 1950 (when p s y c h o t r o p i c d r u g s were d i s c o v e r e d ) t o 198 0, t h e number o f p s y c h i a t r i s t s i n t h e U n i t e d S t a t e s i n c r e a s e d f r o m 1,000 t o 25,000. A l o n g w i t h t h e i r i n c r e a s e i n number came a d i v e r s i f i c a t i o n i n t h e i r power b a s e . P s y c h i a t r i s t s came t o p l a y i m p o r t a n t r o l e s i n t h e c r i m i n a l j u s t i c e s y s t e m s , s c h o o l s , t h e m i l i t a r y and i n community b a s e d s e r v i c e s , and l a s t b u t n o t l e a s t , i n t h e h e a l t h c a r e s y s t e m . To s u p p o r t t h e i r t a s k , t h e y h a v e r e q u i r e d v a r i o u s s u b o r d i n a t e p r o f e s s i o n a l and p a r a - p r o f e s s i o n a l p o s i t i o n s s u c h a s p s y c h i a t r i c n u r s e s , and p s y c h i a t r i c s o c i a l w o r k e r s t o name j u s t a few. S i n c e power r a r e l y comes w i t h o u t money, a t l e a s t w i t h i n c a p i t a l i s t s o c i e t y , d o c t o r ' s income i n Canada ( i n c l u d i n g t h a t o f s p e c i a l i s t s s u c h a s p s y c h i a t r i s t s ) i n c r e a s e d by 136 p e r c e n t b e t w e e n 1962 and 1972 w h i c h was 6.5 t i m e s t h a t o f t h e a v e r a g e i n d u s t r i a l wage f o r t h a t p e r i o d o f t i m e ( S w a r t z , 1 9 7 7 ) . E v a n s (1983) r e p o r t s t h a t one o f t h e means by w h i c h d o c t o r s make t h e i r b u s i n e s s more l u c r a t i v e i s by i n c r e a s i n g t h e i r s t a t u s f r o m g e n e r a l p r a c t i t i o n e r t o t h a t o f s p e c i a l i s t , e.g., p s y c h i a t r i s t , s o t h a t t h e y c a n c l a i m 18 h i g h e r f e e s f o r t h e s e r v i c e s r e n d e r e d . T h e r e f o r e , t r e a t i n g m e n t a l i l l n e s s became a p r o f i t a b l e v e n t u r e f o r t h e m e d i c a l p r o f e s s i o n . P r o f i t s were a l s o g e n e r a t e d f o r h e a l t h c a r e r e l a t e d i n d u s t r i e s . P s y c h i a t r y became a m a r k e t o u t l e t f o r l a r g e p h a r m a c e u t i c a l c o m p a n i e s who b e g a n t h e p r o d u c t i o n o f p s y c h o t h r o p i c m e d i c a t i o n s . T r a n q u i l i z e r s a l o n e became p a r t o f a 100 m i l l i o n d o l l a r a y e a r i n d u s t r y ( L e x c h i n , 1 9 84). And b e c a u s e i t i s t h e d o c t o r s who c h o o s e t h e d r u g r a t h e r t h a n t h e consumer, d r u g c o m p a n i e s s t a r t e d t o p r o m o t e t h e i r p r o d u c t s a l m o s t e x c l u s i v e l y t o them t o t h e t u n e o f o v e r $150 m i l l i o n a y e a r ( L e x c h i n , 1 9 8 4 ) . The g o a l o f t h e a d v e r t i s i n g c a m p a i g n was t o t r a n s f o r m p h y s i c i a n s i n t o h i g h p r e s c r i b e r s o f d r u g s t h r o u g h m a r k e t i n g s t r a t e g i e s t h a t i n c l u d e d a d v e r t i s i n g , d i r e c t m a i l i n g , d i s t r i b u t i o n o f f r e e s a m p l e s , g i f t s , and s a l e s r e p r e s e n t a t i v e s . D r u g c o m p a n i e s a l s o h a d a l a r g e i n v e s t m e n t i n e n c o u r a g i n g t h e c r e a t i o n o f d e v i a n c e , e s p e c i a l l y i f i t c o u l d be b i o - c h e m i c a l l y t r e a t e d . H i s t o r i c a l l y t h e n , p s y c h i a t r y and i t s a l l i e d m e d i c a l e n t r e p r e n e u r s g r a d u a l l y c o r n e r e d a p r o f i t a b l e m a r k e t on d e v i a n c e by t r a n s f o r m i n g i t i n t o m e n t a l i l l n e s s . T h i s p r o c e s s h e r e w i l l be r e f e r r e d t o a s t h e m e d i c a l i z a t i o n o f d e v i a n c e . As F r i e d s o n (1970) r e p o r t s , t h e m e d i c a l p r o f e s s i o n m e d i c a l i z e s d e v i a n c e by d i s c o v e r i n g new i l l n e s s e s and d e v i s i n g a p p r o p r i a t e m e d i c a l t r e a t m e n t . He adds t h a t : 19 One o f t h e g r e a t e s t a m b i t i o n s o f t h e p h y s i c i a n i s t o d i s c o v e r and d e s c r i b e a "new" d i s e a s e o r syndrome and t o be i m m o r t a l i z e d by h a v i n g h i s name u s e d t o i d e n t i f y t h e d i s e a s e . M e d i c i n e , t h e n , i s o r i e n t e d t o s e e k i n g o u t and f i n d i n g i l l n e s s , w h i c h i s t o s a y t h a t i t s e e k s t o c r e a t e s o c i a l m e a n i n g s o f i l l n e s s where t h a t m e a n i n g o r i n t e r p r e t a t i o n was l a c k i n g b e f o r e . (p.152) T h i s t r e n d o f s e e k i n g o u t i l l n e s s i s most p r o n o u n c e d i n t h e f i e l d o f p s y c h i a t r y where d e f i n i n g what i s m e n t a l i l l n e s s and what i s ' h e a l t h y 1 and ' n o r m a l ' b e h a v i o r r e m a i n s an e v e n more c o n t e n t i o u s i s s u e t h a n i n t h e f i e l d o f p h y s i o l o g i c a l m e d i c i n e . C o n r a d (1981) r e p o r t s t h e c a s e o f a t t e n t i o n -d e f i c i t h y p e r a c t i v i t y d i s o r d e r (ADHD) as an example o f a p s y c h i a t r i c d i a g n o s i s i n t h e m a k i n g . T h i s d i a g n o s i s i n c l u d e s s u c h b e h a v i o r s a s e x c e s s m o t o r a c t i v i t y , s h o r t a t t e n t i o n s p a n , r e s t l e s s n e s s , c h a n g i n g mood s w i n g s , i m p u l s i v i t y , i n a b i l i t y t o s i t s t i l l i n s c h o o l and comply w i t h r u l e s , and s l e e p i n g p r o b l e m s . Y e t p r i o r t o t h e " d i s c o v e r " o f ADHD by t h e p s y c h i a t r i c p r o f e s s i o n a l , t h e s e b e h a v i o r s r e c e i v e d m i n i m a l a t t e n t i o n f r o m t h e m e d i c a l p r o f e s s i o n . C o n r a d ( I b i d ) m e n t i o n s t h a t i n f a c t t h e d i s o r d e r . . . . . . s t i l l r e m a i n e d unnamed o r a t l e a s t went by a v a r i e t y o f names ( u s u a l l y s i m p l y " C h i l d h o o d b e h a v i o r d i s o r d e r " ) and d i d n o t e x i s t as a s p e c i f i c d i a g n o s t i c c a t e g o r y u n t i l M a u r i c e W. L a u f e r and h i s a s s o c i a t e s d e s c r i b e d i t a s t h e " h y p e r k i n e t i c i m p u l s e d i s o r d e r " i n 1957. (p.156) T h i s e v e n t o pened t h e d o o r t o t h e f a b r i c a t i o n o f a new d i a g n o s i s . A t a s k f o r c e s p o n s o r e d by t h e U.S. P u b l i c H e a l t h S e r v i c e and t h e N a t i o n a l A s s o c i a t i o n f o r C r i p p l e d C h i l d r e n 20 and A d u l t s a g r e e d on t h e o f f i c i a l d i a g n o s i s o f " M i n i m a l b r a i n d y s f u n c t i o n " ( C l e m e n t s , 1 9 6 6 ) . C o n c u r r e n t t o t h i s t a s k f o r c e was t h e c r e a t i o n o f t h e s y n t h e t i c d r u g m e t h y l p h e n i d a t e ( R i t a l i n ) w h i c h became i n c r e a s i n g l y t h e most p o p u l a r m e d i c a t i o n f o r t r e a t i n g t h e n e w l y l a b e l e d d i s o r d e r . A l a r g e number o f m e d i c a l p a p e r s were p u b l i s h e d on ADH ( C o l e , Sherwood, 1976; D e l o n g , 1 9 7 2 ) . I n t e r e s t i n g l y enough, s e v e n t y - f i v e p e r c e n t o f t h e s e p a p e r s were c o n c e r n e d w i t h d r u g t r e a t m e n t o f t h e d i s o r d e r ( C o n r a d , 1 9 8 1 ) . As a r e s u l t , ADHD became t h e most common c h i l d p s y c h i a t r i c p r o b l e m i n l e s s t h a n a d e c a d e ( G r o s s and W i l s o n , 1 9 7 4 ) . A l o n g w i t h t h e i n c r e a s e i n t h e p o p u l a r i t y o f t h e d i s o r d e r came an i n c r e a s e i n p r o f i t s f o r t h e d r u g company p r o d u c i n g t h e " t r e a t m e n t o f c h o i c e " f o r t h e d i s o r d e r . The company CIBA w h i c h p r o d u c e s R i t a l i n r e a l i z e d a $13 m i l l i o n p r o f i t f r o m t h a t p r o d u c t a l o n e w h i c h a c c o u n t e d f o r 15% o f i t s t o t a l g r o s s p r o f i t s i n 1971 ( C h a r l e s , 1 9 7 1 ) . T h e s e f a c t s l e a d C o n r a d (1981) t o q u e s t i o n " w h e t h e r t h e d e v e l o p m e n t o f new m e d i c a l mechanism o f s o c i a l c o n t r o l i n t h e f o r m o f p s y c h o t r o p i c d r u g s l e a d s t o t h e emergence o f new c a t e g o r i e s o r d e s i g n a t i o n s o f d e v i a n c e and t h e e x p a n s i o n o f m e d i c a l j u r i s d i c t i o n " ( p . 1 6 1 ) . The example o f a t t e n t i o n - d e f i c i t d i s o r d e r s e r v e s t o i l l u s t r a t e t h a t t h e g r o w i n g power o f p s y c h i a t r i s t s h a s b een p a r t l y as a r e s u l t o f t h e i r a b i l i t y t o r e d e f i n e d e v i a n t b e h a v i o r s i n m e d i c a l t e r m s and i d e n t i f y t h e i r s i g n s and symptoms w h i c h c a n be g r o u p e d i n d i a g n o s t i c c a t e g o r i e s f o r w h i c h t h e n b i o - c h e m i c a l t r e a t m e n t s c a n be d e v e l o p e d . S z a s z (1961) a r g u e s t h a t s u c h r e d e f i n i t i o n i s i n f a c t t h e p r o c e s s by w h i c h p s y c h i a t r y c r e a t e s what he c a l l s " t h e myth o f m e n t a l i l l n e s s " . A l t h o u g h " m e n t a l i l l n e s s e s s " a r e r e g a r d e d a s b a s i c a l l y no d i f f e r e n t t h a n a l l o t h e r d i s e a s e s o f t h e body by p s y c h i a t r i s t s , he b e l i e v e s s u c h i l l n e s s e s o f mind a r e more ' p r o b l e m s o f l i v i n g 1 stemming f r o m d i f f e r e n c e s i n p e r s o n a l n e e d s , o p i n i o n s , s o c i a l a s p i r a t i o n s , v a l u e s and so on w h i c h , w i t h i n t h e m e d i c a l p e r s p e c t i v e , a r e a t t r i b u t e d t o p h y s i o l o g i c a l p r o c e s s e s w h i c h i n due t i m e w i l l be d i s c o v e r e d by m e d i c a l r e s e a r c h and t r e a t e d w i t h m e d i c a l t e c h n o l o g y . To a c h i e v e t h i s g o a l , p s y c h i a t r y h a s g r o u p e d m e n t a l i l l n e s s * v a r i o u s s i g n s and symptoms i n t o d i a g n o s t i c c a t e g o r i e s w h i c h a r e c o n t a i n e d most r e c e n t l y i n t h e t h i r d r e v i s e d e d i t i o n o f t h e A m e r i c a n ' s P s y c h i a t r i c A s s o c i a t i o n ' s (1987) Diagnostic and Statistical Manual of Mental Disorders. The aim o f t h e manual i s t o g u i d e t h e p s y c h i a t r i s t s i n c l a s s i f y i n g d i s t u r b e d i n d i v i d u a l s . i n p a r t i c u l a r d i a g n o s t i c c a t e g o r i e s f o r w h i c h t h e n a s p e c i f i c t r e a t m e n t c a n be d e v e l o p e d and a p p l i e d . Cockerham (1981) d e s c r i b e s t h e h i d d e n agenda b e h i n d t h i s a p p r o a c h a s "one o f m a k i n g p s y c h i a t r y one o f t h e most s c i e n t i f i c a l l y p r e c i s e o f a l l m e d i c a l s p e c i a l t i e s and e n d i n g i t s d e p e n d e n c y on s u b j e c t i v e j u d g e m e n t s o f and i n s i g h t s i n t o t h e human mind" (p. 7 9 - 8 0 ) . Y e t t h e DSM I I I - R ( I b i d ) , d e f i n e s m e n t a l d i s o r d e r s v e r y b r o a d l y a s b e i n g p r a c t i c a l l y any s i g n i f i c a n t d e v i a t i o n f r o m 22 some i d e a l s t a n d a r d o f p o s i t i v e m e n t a l h e a l t h . T h e r e f o r e , t h e c o n c e p t s o f m e n t a l d i s o r d e r o f t e n c hange t o accommodate t h e c h a n g i n g v a l u e s and p r o f e s s i o n a l s * j u d g e m e n t s . P o t e n t i a l l y , t h e l a r g e s t numbers o f p r o b l e m s o f l i v i n g f o r p s y c h i a t r y t o d i a g n o s e as i l l n e s s a r e t o be f o u n d i n t h e l o w e r s o c i a l c l a s s e s and t h a t f o r a number o f r e a s o n s . F i r s t , t h e r e a r e much l a r g e r numbers o f p e o p l e i n t h e l o w e r c l a s s t h a n i n t h e m i d d l e and u p p e r c l a s s e s and h e n c e t h e i r s h e e r numbers makes them more l i k e l y f o r h i g h e r i n c i d e n c e s o f d e v i a n t b e h a v i o r . S e c o n d l y , h i g h e r s t a t u s p e r s o n s a r e more a b l e t o r e s i s t b e i n g i d e n t i f i e d a s m e n t a l l y i l l b e c a u s e o f t h e i r g r e a t e r r e s o u r c e s o f w e a l t h , power, and s t a t u s where a s i n c o n t r a s t , l o w e r c l a s s p e r s o n s a r e l e s s a b l e t o r e s i s t b e i n g l a b e l e d b e c a u s e o f t h e i r p o w e r l e s s c o n d i t i o n ( S c h e f f , 1 9 6 6 ) . A l s o , h i g h e r s o c i a l c l a s s e s d e f i n e s n o r m a t i v e b e h a v i o r t h r o u g h r u l e s and s a n c t i o n s . T h e r e f o r e , t h e l o w e r s o c i a l c l a s s i s more l i k e l y t o e x h i b i t d e v i a n c e u n l e s s i t c o n f o r m s t o t h e s e r u l e s and s a n c t i o n s . S i n c e many o f t h e d e v i a n t b e h a v i o r s t e n d t o be d e f i n e d a l o n g m o r a l l i n e s a l t h o u g h t h e y a r e p r e s e n t e d a s m e d i c a l p r o b l e m s ( h o m o s e x u a l i t y i s a good example o f t h a t ) , t h e l o w e r c l a s s e s a r e more l i k e l y t o d e v i a t e as t h e i r norms and v a l u e s d i f f e r f r o m t h a t o f t h e u p p e r c l a s s e s . W i t h i n t h i s framework t h e n , p s y c h i a t r i s t s c a n be s e e n a s m o r a l e n t r e p r e n e u r s whose t a s k i s t o e n f o r c e t h e norms and v a l u e s o f t h e u p p e r c l a s s o n t o t h e l o w e r c l a s s ( S z a s z , 1 9 83). 23 F i n a l l y , s o c i a l s t r e s s o r s s u c h as p o v e r t y , unemployment and g e n e r a l l y d e p r i v e d l i v i n g c o n d i t i o n s w h i c h c a n be s o u r c e s o f d e v i a n c e t e n d t o be more p r e v a l e n t i n t h e l o w e r s o c i a l c l a s s t h a n i n t h e m i d d l e and u p p e r c l a s s e s ( K e s s l e r , 1979) . The r a t e o f m e n t a l h o s p i t a l i z a t i o n s h a s b een shown t o i n c r e a s e d r a m a t i c a l l y d u r i n g e c o n o m i c d o w n t u r n s , and t o d e c r e a s e e q u a l l y d u r i n g u p t u r n s ( B r e n n e r , 1 9 7 3 ) . S i n c e t h e l o w e r s o c i a l c l a s s i s most a f f e c t e d by e c o n o m i c d o w n t u r n s t h o s e p e r s o n s w i t h t h e l o w e s t s o c i o - e c o n o m i c s t a t u s e x i s t i n g l a r g e l y on p u b l i c w e l f a r e a r e most l i k e l y t o be l a b e l e d m e n t a l l y i l l a nd h a v e r a t e s o f m e n t a l h o s p i t a l a d m i s s i o n s t w i c e a s h i g h a s t h o s e o f o t h e r more a f f l u e n t s o c i o e c o n o m i c g r o u p s ( I b i d ) . F u r t h e r m o r e , l o w e r c l a s s p a t i e n t s t e n d t o r e c e i v e c u s t o d i a l c a r e o r s o m a t i c t r e a t m e n t s , where as h i g h e r c l a s s p a t i e n t s a r e more l i k e l y t o r e c e i v e r e h a b i l i t a t i v e f o r m s o f c a r e s u c h as p s y c h o t h e r a p y ( H o l l i n g s h e a d and R e d l i c h , 1958) . As a r e s u l t , p a t i e n t s f r o m t h e l o w e s t s o c i a l c l a s s t e n d t o h a v e by f a r t h e l o n g e s t p e r i o d o f h o s p i t a l i z a t i o n , and r e m a i n m e n t a l l y i l l f o r l o n g e r p e r i o d s o f t i m e ( I b i d ) . O v e r a l l t h e n , t h e l o w e r s o c i a l c l a s s i s l i k e l y t o d i s p l a y h i g h e r r a t e s o f m e n t a l i l l n e s s b e c a u s e o f i t s p r o p e n s i t y t o e x h i b i t more d e v i a n t b e h a v i o r d e f i n e d as s u c h by t h e h i g h e r s o c i a l c l a s s e s . T h i s i s a r e s u l t o f t h e d i s a d v a n t a g e d s o c i a l c o n d i t i o n s t h e y l i v e i n w h i c h c a n l e a d t o i m p a i r e d e m o t i o n a l h e a l t h f o r w h i c h t h e y r e c e i v e 24 i n a d e q u a t e c a r e , and b e c a u s e o f t h e i r d i f f e r i n g norms and v a l u e s c o n t r a v e n i n g t h o s e w h i c h a r e e n f o r c e d by d o m i n a n t s o c i a l g r o u p s . W i t h i n t h i s framework t h e n , p s y c h i a t r i s t s a c t a s a g e n t s o f t h e d o m i n a n t c l a s s t o c o n t r o l d e v i a n c e i n t h e l o w e r s o c i a l c l a s s . MEDICALIZATION, THE ELDERLY AND PSYCHIATRY B e c a u s e o f t h e i r l o w e r s o c i o - e c o n o m i c s t a t u s t h e e l d e r l y t e n d t o be members o f t h e l o w e r s o c i a l c l a s s and t h e r e f o r e a r e more l i k e l y t o be l a b e l e d m e n t a l l y i l l as p s y c h i a t r y s e e k s t o e x p a n d i t s j u r i s d i c t i o n o v e r d e v i a n c e . A c c o r d i n g t o M y l e s ( 1 9 8 4 ) , i n Canada, t h e l o w e r s o c i o -e c o n o m i c s t a t u s o f t h e e l d e r l y i s a d i r e c t r e s u l t o f t h e p o l i c y o f m a n d a t o r y r e t i r e m e n t and t h e e n s u i n g i m p l e m e n t a t i o n o f t h e p e n s i o n s y s t e m w h i c h r e d u c e s an i n d i v i d u a l ' s a v e r a g e income by h a l f a f t e r age 65. A c c o r d i n g t o O l s e n ( 1 9 8 2 ) , t h e demand f o r m a n d a t o r y r e t i r e m e n t r o s e f r o m t h e e x i g e n c i e s o f t h e c a p i t a l i s t economy w i t h i t s e p i s o d i c unemployment, and i t s n e e d f o r a means o f t r a n s f e r r i n g s k i l l s g e n e r a t i o n a l l y i n i n d u s t r i e s owned by t h e d o m i n a n t c l a s s w h i c h e x p e r i e n c e d s u r p l u s l a b o u r . S uch e c o n o m i c i m p e r a t i v e s and g o v e r n m e n t p o l i c i e s a r o u n d r e t i r e m e n t h a v e e s s e n t i a l l y c r e a t e d a new s o c i a l c l a s s made o f i n d i v i d u a l s who b e c a u s e o f t h e i r age h a v e become p o w e r l e s s and i m p o v e r i s h e d s i n c e t h e c a p i t a l i s t economy i s o r g a n i z e d a r o u n d d i f f e r e n t i a l r e w a r d s f o r p r o d u c t i v e l a b o u r , 25 f r o m w h i c h t h e y a r e i n l a r g e p a r t e x c l u d e d . I n 1981, t h e N a t i o n a l C o u n c i l on W e l f a r e (1982) r e p o r t e d t h a t 57 p e r c e n t o f t h e e l d e r l y h a d y e a r l y i n c o m e s u n d e r $2,000. The p o v e r t y l i n e f o r a s i n g l e p e r s o n ' s income f o r t h a t y e a r was s e t a t $6,521.00. The e l d e r l y ' s low s o c i o - e c o n o m i c s t a t u s c a n r e s u l t i n a s i g n i f i c a n t i n c r e a s e i n t h e s t r e s s t h e y f a c e w h i l e s t r u g g l i n g f o r t h e i r s u r v i v a l . T h i s i n t u r n c a n n e g a t i v e l y i m p a c t t h e i r m e n t a l w e l l - b e i n g . Many o f t h e a i l m e n t s a f f e c t i n g o l d e r p e o p l e c a n be t r a c e d b a c k t o p o v e r t y t h r o u g h o u t t h e i r l i f e t i m e s and e v e n g r e a t e r p o v e r t y upon a t t a i n i n g age s i x t y - f i v e . One's s t a n d a r d o f l i v i n g may be t h e m a i n d e t e r m i n a n t o f h e a l t h and d e c e a s e . S t u d i e s o f t h e e f f e c t s o f s o c i a l c l a s s membership on h e a l t h show c o n s i s t e n t l y t h a t l o w e r c l a s s s t a t u s p r e d i c t s s h o r t e r l i f e e x p e c t a n c y , and h i g h e r d e a t h and m o r b i d i t y r a t e s f r o m a l l d i s e a s e s ( H a r r i s e t a l . , 1976; T e s h , 1 9 8 1 ) . More s p e c i f i c a l l y , H a r r i s ' (1976) s u r v e y on t h e a g e d i n d i c a t e d t h a t o f t h e 50 p e r c e n t o f t h o s e s u r v e y e d who c o n s i d e r e d p o o r h e a l t h a s a s e r i o u s p r o b l e m i n t h e i r l i v e s , 3 6 p e r c e n t o f them ha d y e a r l y i n c o m e s u n d e r $3,000. B u t l e r (197 5) n o t e s t h a t w e a l t h p r o v i d e s g r e a t e r o p p o r t u n i t y f o r r e s t , s o u n d n u t r i t i o n , a d e q u a t e h o u s i n g , e m o t i o n a l s e c u r i t y , r e d u c e d s t r e s s , and t h e c a p a c i t y t o h a v e i l l n e s s t r e a t e d . S i n c e w e a l t h e v e n i n m o d e r a t e amounts i s n o t a v a i l a b l e t o many e l d e r l y , i t ' s r e a s o n a b l e t o v e n t u r e t h a t t h e y w i l l s u f f e r f r o m p o o r n u t r i t i o n , l i v e i n i n a d e q u a t e h o u s i n g , e x p e r i e n c e 26 more s t r e s s and e m o t i o n a l i n s t a b i l i t y , a nd c o n s e q u e n t l y be a t i n c r e a s e d r i s k f r o m d e v e l o p i n g " p r o b l e m s o f l i v i n g ' w h i c h w i l l be l a b e l e d a s m e n t a l i l l n e s s by t h e p s y c h i a t r i c p r o f e s s i o n . I n f a c t t h i s t r e n d i s a l r e a d y a p p a r e n t when r e v i e w i n g t h e e p i d e m i o l o g i c a l s t u d i e s on t h e r a t e s o f m e n t a l i l l n e s s i n t h e e l d e r l y a s d e f i n e d by p s y c h i a t r i c s t a n d a r d s . I n t h e s e s t u d i e s , t h e e l d e r l y a r e g e n e r a l l y c o n s i d e r e d more l i k e l y t h a n y o u n g e r age g r o u p s t o s u f f e r f r o m p s y c h i a t r i c i m p a i r m e n t s . B l a z e r (1980) summarizes a v a r i e t y o f e p i d e m i o l o g i c a l s t u d i e s w h i c h r e p o r t s i g n i f i c a n t l y h i g h e r r a t e s o f p s y c h i a t r i c d i s o r d e r s among t h o s e 65 and o v e r . The a u t h o r n o t e s t h a t r a n g e s o f 10 t o 4 0 p e r c e n t o f t h e community's e l d e r l y h a v e b e e n r e p o r t e d a s p s y c h i a t r i c a l l y i m p a i r e d i n a v a r i e t y o f s t u d i e s . B u t l e r (1975) a l s o r e p o r t s h i g h e s t i m a t e s o f i n c i d e n c e o f p s y c h i a t r i c i m p a i r m e n t s i n t h e e l d e r l y p o p u l a t i o n a s compared t o y o u n g e r p o p u l a t i o n s . T h e y a r e : 2.3 p e r 100,000 i n t h e u n d e r 14 age g r o u p ; 76.3 i n t h e 2 5 t o 3 4 age g r o u p ; 9 3.0 i n t h e 3 5 t o 64 age g r o u p ; and 2 3 5.1 i n t h e o v e r 65 age g r o u p . T h e s e i n c r e a s e d r a t e s o f m e n t a l i l l n e s s d i a g n o s e d by p s y c h i a t r i s t s c a n be c o n s i d e r e d a s i n d i c a t i v e o f t h e i r a b i l i t y t o r e d e f i n e w i t h i n t h e b i o - m e d i c a l framework many c o n d i t i o n s w h i c h were p r e v i o u s l y s e e n a s stemming f r o m a l i f e o f h a r d s h i p , o r s i m p l y f r o m t h e p r o c e s s o f g r o w i n g o l d e r . T h e s e p r o b l e m s were u s u a l l y t a k e n c a r e o f w i t h i n t h e t r a d i t i o n a l n e t w o r k s o f t h e f a m i l y and o f t h e community. 27 F o r example, i f an e l d e r l y was f o u n d t o be l o n e l y , i s o l a t e d , a n d s a d , f a m i l y members, and community members w o u l d v i s i t , a nd o r a r r a n g e o u t i n g s t o i m p r o v e h i s o r h e r c o n d i t i o n . T o d a y however, p s y c h i a t r y h a s d i c t a t e d a new a p p r o a c h t o t h i s p r o b l e m by r e d e f i n i n g i t a s d e p r e s s i v e d i s o r d e r ( w h i c h i s t h e most common d i s o r d e r d i a g n o s e d i n t h e e l d e r l y ) , and p r e s c r i b i n g a t r e a t m e n t c o u r s e o f a n t i - d e p r e s s a n t m e d i c a t i o n t o c u r e t h e i n d i v i d u a l s u f f e r i n g f r o m i t . T h i s p r o c e s s o f t r a n s f o r m i n g ' p r o b l e m s l i v i n g ' i n e l d e r l y i n t o m e n t a l i l l n e s s w i l l be r e f e r r e d h e r e as m e d i c a l i z i n g d e v i a n c e . The p u r p o s e o f t h i s s t u d y t h e n i s t o d e m o n s t r a t e how t h e p r o c e s s o f m e d i c a l i z i n g d e v i a n c e o p e r a t e s w i t h i n a community m e n t a l h e a l t h team o f f e r i n g s p e c i a l i z e d g e r i a t r i c s e r v i c e s t o t h e e l d e r l y i n i t s c a t c h m e n t a r e a . 28 CHAPTER 2 METHODOLOGY The q u i n t e s s e n t i a l t a s k f a c i n g t h e r e s e a r c h e r i s c h o o s i n g t h e b e s t s u i t e d method (s) t o i n v e s t i g a t e t h e p r o b l e m (s) a t hand. T h i s c h a p t e r i n t r o d u c e s t h e m e t h o d o l o g i c a l themes f o r t h i s s t u d y by o u t l i n i n g i t s t h e o r e t i c a l f ramework and l i s t i n g t h e r e s e a r c h h y p o t h e s e s w h i c h g u i d e d t h i s r e s e a r c h e r i n h i s i n v e s t i g a t i o n . I n c l u d e d h e r e a r e a l s o a d e s c r i p t i o n o f t h e f i e l d s t r a t e g y and methods o f d a t a c o l l e c t i o n , and d i s c u s s i o n o f t h e t h r e a t s t o r e l i a b i l i t y and v a l i d i t y o f t h e f i n d i n g s and how t h o s e were d e a l t w i t h i n t h e c o u r s e o f t h e s t u d y . THEORETICAL FRAMEWORK The t h e o r e t i c a l framework f o r t h i s i n v e s t i g a t i o n i s one w h i c h a d v a n c e s t h a t m e n t a l i l l n e s s c a n be v i e w e d a s d e v i a n c e w h i c h i s i d e n t i f i e d and s a n c t i o n e d i n t h e l o w e r s o c i a l c l a s s e s by t h e d o m i n a n t c l a s s t h r o u g h i t s p s y c h i a t r i c a p p a r a t u s . A l t h o u g h a l l s o c i e t i e s t h r o u g h o u t h i s t o r y h a v e i n one way o r a n o t h e r a t t e m p t e d t o c o n t r o l t h e i r d e v i a n t members, i t i s o n l y i n t h e l a s t c e n t u r y o r s o t h a t p s y c h i a t r y h a s emerged as a mechanism t h r o u g h w h i c h d e v i a n t b e h a v i o r i s b e i n g d e f i n e d , i d e n t i f i e d and t r e a t e d . The g r o w t h o f p s y c h i a t r y a s a s o c i a l c o n t r o l a g e n t c a n be a t t r i b u t e d t o t h e d e s i r e by t h e m e d i c a l p r o f e s s i o n t o i n c r e a s e i t s power and p r o f i t a b i l i t y . As a b r a n c h o f m e d i c i n e , p s y c h i a t r y s o u g h t t o a d o p t a s c i e n t i f i c 29 e x p l a n a t o r y model t o e x p l a i n b e h a v i o r s i n i n d i v i d u a l s w h i c h d e v i a t e d f r o m s o c i a l l y a c c e p t a b l e norms. D e v i a n t b e h a v i o r t h e n became t h e e x p r e s s i o n o f u n d e r l y i n g d y s f u n c t i o n a l o r g a n i c p r o c e s s e s . P s y c h i a t r y a l s o i n c r e a s e d t h e r a n g e o f d e v i a n t b e h a v i o r s w h i c h c o u l d be d i a g n o s e d a s p s y c h i a t r i c d i s o r d e r s . T h i s was i n r e s p o n s e t o t h e e c o n o m i c c o n s t r a i n t s o f t h e c a p i t a l i s t economy t o w h i c h p s y c h i a t r y was s u b j e c t e d i n i t s e x p a n s i o n . I n c r e a s e d p r o f i t a b i l i t y came f r o m e x p a n d i n g t h e r a n g e o f p r o b l e m s d i a g n o s e d a s p s y c h i a t r i c d i s o r d e r s and by i n c r e a s i n g t h e p r i c e a s k e d f o r t h e i r t r e a t m e n t t h r o u g h s p e c i a l i z a t i o n . I n Canada, t h e s e p r o f i t s came m a i n l y f r o m s t a t e payments t h r o u g h m e d i c a l i n s u r a n c e schemes. F u r t h e r m o r e , t h e n e e d f o r t h e c r e a t i o n and d e l i v e r y o f s p e c i a l i z e d t r e a t m e n t a l s o l e d t o t h e f o r m a t i o n o f a l a r g e m e d i c a l i n d u s t r i a l c omplex r e s p o n s i b l e f o r r e s e a r c h i n g and f a b r i c a t i n g i n c r e a s i n g l y more comp l e x and c o s t l y t r e a t m e n t s . The p r o f i t - m a k i n g i m p e r a t i v e s o f t h i s c o m p l e x h a v e a l s o i m p a c t e d on p s y c h i a t r i s t s who o f t e n a c t a s d i s t r i b u t i n g a g e n t s o f t h e s e t r e a t m e n t s . The e l d e r l y b e c a u s e o f t h e i r d i s a d v a n t a g e d s o c i o - e c o n o m i c p o s i t i o n a r e more l i k e l y t o be l a b e l l e d a s m e n t a l l y i l l a s t h e d o m i n a n t c l a s s s e e k t o c o n t r o l a new f o r m o f d e v i a n c e , t h a t o f a g i n g , and a l s o a s p s y c h i a t r y s e e k s t o e x p a n d t h e i r m a r k e t f o r new d i a g n o s i s . F i n a l l y , p s y c h i a t r i s t s a l s o a c t as a g e n t s o f s o c i a l c o n t r o l f o r t h e d o m i n a n t c l a s s by p u t t i n g t h e r e s p o n s i b i l i t y o f s o c i a l p r o b l e m s on i n d i v i d u a l c a u s e s , and t h e s o l u t i o n t o t h e s e p r o b l e m s on i n d i v i d u a l t r e a t m e n t , h e n c e t a k i n g away t h e 30 f o c u s f r o m t h e i n e q u a l i t i e s w i t h i n l a r g e r s o c i a l s y s t e m s . Ryan (1971) h a s i d e n t i f i e d t h i s p r o c e s s a s " b l a m i n g t h e v i c t i m " : s e e i n g t h e c a u s e s o f t h e p r o b l e m i n i n d i v i d u a l s (who a r e u s u a l l y o f l o w e r s t a t u s ) r a t h e r t h a n e n d e m i c t o t h e s o c i e t y . Hence, by l a b e l i n g c o n f u s e d , i s o l a t e d , and d i s t r e s s e d e l d e r l y as demented o r d e p r e s s e d , we i g n o r e t h e m e a n i n g o f t h e s e b e h a v i o r s i n t h e c o n t e x t o f t h e s o c i a l s y s t e m . P u t t i n g t h e f o c u s on t h e s y s t e m on t h e o t h e r hand m i g h t r e v e a l t h e i n a d e q u a t e s o c i a l c o n d i t i o n s many e l d e r l y l i v e i n b e c a u s e o f f o r c e d r e t i r e m e n t , i n c l u d i n g b e l o w p o v e r t y l e v e l i n c o m e s , i n a d e q u a t e h o u s i n g , and e x c l u s i o n f r o m a c t i v e s o c i a l r o l e s . A l l t h e s e f a c t o r s c a n h a v e a n e g a t i v e i m p a c t on t h e i r e m o t i o n a l w e l l b e i n g . T h e s e c o n d i t i o n s e x i s t a s a e s u l t o f t h e e x i g e n c i e s o f a c a p i t a l i s t economy w h i c h r e q u i r e s a s t a t e p o l i c y o f m a n d a t o r y r e t i r e m e n t a s a means o f t r a n s f e r r i n g s k i l l s g e n e r a t i o n a l l y i n i n d u s t r i e s w i t h s u r p l u s l a b o u r ( O l s o n , 1 9 8 2 ) . Hence, by m e d i c a l i z i n g d e v i a n t b e h a v i o r i n t h e e l d e r l y , p s y c h i a t r y p r e c l u d e s us f r o m r e c o g n i z i n g i t as p o s s i b l e r e a c t i o n s t o t h e e x p l o i t a t i v e p o l i t i c a l a r r a n g e m e n t s t h a t s e r v e t h e b e n e f i t s o f t h e d o m i n a n t c l a s s t o t h e d e t r i m e n t o f t h e w o r k i n g c l a s s . HYPOTHESES From t h i s framework, I d e v e l o p e d a number o f g e n e r a l h y p o t h e s e s t o g u i d e my i n v e s t i g a t i o n o f t h e p r o c e s s o f 31 m e d i c a l i z a t i o n i n a community m e n t a l h e a l t h team. The h y p o t h e s e s a r e : (a) I f d e v i a n c e i s a s o c i a l l y a t t r i b u t e d c o n d i t i o n , t h e n m e n t a l i l l n e s s a s s u c h i n t h e e l d e r l y i s b e h a v i o r w h i c h v i o l a t e s t h e e x p e c t e d norms a n d / o r r u l e s o f c o n d u c t o f t h e s o c i a l g r o u p w h i c h t h e d e v i a n t i n d i v i d u a l b e l o n g s t o . F o r example, t h e i n s t i t u t i o n s s e r v i n g t h e e l d e r l y w o u l d h a v e a t e n d e n c y t o d e f i n e d e v i a n t b e h a v i o r i n t h e i r c l i e n t e l e a s s y m p t o m a t i c o f m e n t a l i l l n e s s i f s u c h b e h a v i o r i n t e r f e r e d w i t h t h e p r o p e r and e f f i c i e n t r u n n i n g o f t h a t i n s t i t u t i o n . (b) The d e f i n i t i o n and s a n c t i o n i n g o f d e v i a n c e i m p l i e s a r e l a t i o n s h i p o f power i n w h i c h t h e d e v i a n t e l d e r l y i s s i g n i f i c a n t l y l e s s p o w e r f u l t h a n t h e g r o u p d o i n g t h e l a b e l i n g . Power h e r e i s u n d e r s t o o d i n t e r m s o f g e n d e r , age, s o c i o -e c o n o m i c s t a t u s ( e d u c a t i o n , income, s o c i a l c l a s s ) , b u t a l s o i n t e r m s o f d e p e n d e n c y i s s u e s , e .g., d e p e n d e n t on p e n s i o n f o r income, d e p e n d e n t on n u r s i n g home f o r p e r s o n a l c a r e . (c) P s y c h i a t r y (and r e l a t e d p r o f e s s i o n a l s ) t e n d t o l a b e l and c o n t r o l an i n c r e a s i n g l y w i d e r r a n g e o f d e v i a n c e a s m e n t a l i l l n e s s i n t h e e l d e r l y i n an e f f o r t t o e x p a n d t h e i r power and p r o f i t a b i l i t y . T h i s t e n d e n c y i n c r e a s e s t h e l i k e l i h o o d t h a t p r o b l e m s o f l i v i n g f a c e d by t h e e l d e r l y due t o t h e i r low s o c i o - e c o n o m i c s t a t u s a r e t r a n s f o r m e d w i t h i n t h e b i o - m e d i c a l f ramework i n t o p s y c h i a t r i c d i s o r d e r . C o n f i r m a t i o n o f t h e above m e n t i o n e d h y p o t h e s e s w o u l d a l s o i n d i c a t e t h a t t h e Community M e n t a l H e a l t h Team f u n c t i o n s an a g e n t o f s o c i a l c o n t r o l f o r t h e d o m i n a n t c l a s s and i t s i n s t i t u t i o n s . RESEARCH SETTINGS I n o r d e r t o v e r i f y t h e s e h y p o t h e s e s , I d e c i d e d t o i n v e s t i g a t e t h e d e l i v e r y o f p s y c h i a t r i c s e r v i c e s t o t h e e l d e r l y i n a community m e n t a l h e a l t h team i n t h e u r b a n c o r e o f 32 a l a r g e c i t y . The team i s d e s c r i b e d i n d e t a i l i n C h a p t e r T h r e e . E l d e r l y h e r e r e f e r s t o anyone o v e r t h e age o f s i x t y -f i v e . The d e l i v e r y o f s u c h s e r v i c e s i s done on a v o l u n t a r y b a s i s where p e o p l e o r i n s t i t u t i o n s i n t h e community who d e c i d e t h e y r e q u i r e t h e team's s e r v i c e s make a r e f e r r a l e i t h e r i n p e r s o n o r by phone. To g a i n a b e t t e r u n d e r s t a n d i n g o f w h i c h t y p e o f i n s t i t u t i o n s u t i l i z e d community m e n t a l h e a l t h s e r v i c e s , I i d e n t i f i e d t h e m a i n i n s t i t u t i o n s w h i c h r e f e r r e d e l d e r l y c l i e n t s t o t h e team by i n t e r v i e w i n g t h e team's s t a f f and g a t h e r i n g t h e i r o p i n i o n on t h i s i s s u e . F i v e c a t e g o r i e s o f r e f e r r i n g i n s t i t u t i o n s were s e l e c t e d , and t h e s e were: (a) P s y c h i a t r i c wards - g e n e r a l h o s p i t a l (b) N u r s i n g homes (c) S o c i a l s e r v i c e a g e n c i e s (d) Community o r g a n i z a t i o n s (e) A p a r t m e n t b u i l d i n g s The f o l l o w i n g i s a b r i e f d e s c r i p t i o n o f t h e s e c a t e g o r i e s o f i n s t i t u t i o n s and o f t h e i r r o l e i n r e l a t i o n s h i p t o t h e d e l i v e r y o f community m e n t a l h e a l t h s e r v i c e s . P s y c h i a t r i c W a r d s - G e n e r a l H o s p i t a l D i s t r i b u t e d t h r o u g h o u t t h e p r o v i n c e i n g e n e r a l h o s p i t a l s , t h e s e p s y c h i a t r i c wards a r e u s u a l l y s m a l l , 2 0 b e d s o r s o , and a r e r e s p o n s i b l e f o r t h e management o f l o c a l p s y c h o - p a t h o l o g y f o r s h o r t p e r i o d s o f t i m e , u s u a l l y f r o m a few d a y s t o up t o s e v e r a l months. R e g i o n a l p s y c h i a t r i c wards a r e n o t e q u i p p e d t o h a n d l e l o n g t e r m s e v e r e m e n t a l i l l n e s s and t h e r e f o r e 33 i n d i v i d u a l s r e q u i r i n g l o n g e r t e r m t r e a t m e n t a r e t r a n s f e r r e d t o t h e p r o v i n c i a l f a c i l i t y . N u r s i n g Homes N u r s i n g homes do n o t u s u a l l y o f f e r s e r v i c e s t o t h e p s y c h i a t r i c p o p u l a t i o n b u t r a t h e r t o e l d e r l y i n d i v i d u a l s who a r e i n c a p a b l e o f c a r i n g f o r t h e m s e l v e s i n d e p e n d e n t l y . However, i n d i v i d u a l s w i t h s t a b i l i z e d p s y c h i a t r i c d i s o r d e r s who a r e o v e r t h e age o f 65 a r e o f t e n r e f e r r e d t o n u r s i n g homes f r o m b o t h t h e p r o v i n c i a l and r e g i o n a l f a c i l i t i e s . F u r t h e r m o r e , i n d i v i d u a l s who e n t e r a n u r s i n g home may l a t e r d e v e l o p a p s y c h i a t r i c d i s o r d e r n o t s u f f i c i e n t l y s e v e r e t o j u s t i f y a t r a n s f e r t o h o s p i t a l b u t n e v e r t h e l e s s r e q u i r i n g t r e a t m e n t . N u r s i n g homes v a r y i n s i z e , b u t most t y p i c a l l y h a v e a 3 0 b e d c a p a c i t y a l t h o u g h some c a n accommodate o v e r one h u n d r e d r e s i d e n t s . S o c i a l S e r v i c e A g e n c i e s T h e r e a r e a l a r g e number o f s o c i a l s e r v i c e a g e n c i e s p r o v i d i n g d i r e c t and i n d i r e c t s e r v i c e s t o t h e e l d e r l y . Some o f t h e s e a r e v e r y l a r g e and g o v e r n m e n t r u n . The w e l f a r e o f f i c e s a r e g o o d e x a m p l e s o f t h a t a s t h e y o p e r a t e u n d e r t h e M i n i s t r y o f S o c i a l S e r v i c e s and H o u s i n g t h r o u g h o u t t h e p r o v i n c e . O t h e r a g e n c i e s a r e s m a l l e r and p r i v a t e l y r u n , and u s u a l l y l o c a l i z e d t o one u r b a n a r e a . 34 Community O r g a n i z a t i o n s T h i s c a t e g o r y r e f e r s t o o r g a n i z a t i o n s w h i c h a r e n o t s o c i a l s e r v i c e a g e n c i e s b u t n e v e r t h e l e s s p r o v i d e some f o r m o f s e r v i c e t o t h e e l d e r l y . T h e s e c a n i n c l u d e b a n k s , s e n i o r ' s g r o u p s , and s o on. A p a r t m e n t B u i l d i n g s A p a r t m e n t b u i l d i n g s a r e t h e s i n g l e l a r g e s t t y p e o f h o u s i n g f o r t h e e l d e r l y l i v i n g i n t h e team's c a t c h m e n t a r e a . A l l b u i l d i n g s a r e u s u a l l y 3 s t o r e y s o r more and h a v e a r e s i d e n t manager o r c a r e t a k e r . I n c l u d e d i n t h i s c a t e g o r y a r e g o v e r n m e n t s u b s i d i z e d h o u s i n g p r o j e c t s p u r p o s e l y b u i l t f o r low i ncome s e n i o r s . METHODS OF DATA COLLECTION I s e l e c t e d p a r t i c i p a n t o b s e r v a t i o n a s t h e main m e t h o d o l o g i c a l a p p r o a c h f o r t h i s i n v e s t i g a t i o n . D e n z i n (1978) d e s c r i b e s p a r t i c i p a n t o b s e r v a t i o n a s an omnibus f i e l d s t r a t e g y i n t h a t i t s i m u l t a n e o u s l y c o m b i n e s document a n a l y s i s , i n t e r v i e w o f r e s p o n d e n t s and i n f o r m a n t s , d i r e c t p a r t i c i p a t i o n and o b s e r v a t i o n and i n t r o s p e c t i o n . T h i s s t u d y s i m u l t a n e o u s l y c o m b i n e d r e f e r r a l f orms a n a l y s i s , c a s e s t u d i e s i n v o l v i n g i n t e r v i e w s w i t h f i v e e l d e r l y c l i e n t s r e f e r r e d t o t h e team, t h e i r r e f e r r i n g a g e n t s , and o t h e r k e y i n f o r m a n t s and d i r e c t o b s e r v a t i o n o f t h e r e f e r r a l p r o c e s s . 35 C a s e S t u d y S u b j e c t s f o r t h e c a s e s t u d y s a mple were s e l e c t e d by c h o o s i n g t h e f i r s t r e f e r r a l o f a n e l d e r l y c l i e n t by an i n s t i t u t i o n b e l o n g i n g t o one o f t h e c a t e g o r i e s i d e n t i f i e d i n t h e r e s e a r c h s e t t i n g s e c t i o n . E a c h r e f e r r e d s u b j e c t h a d t o meet two c r i t e r i a t o be i n c l u d e d i n t h e c a s e s t u d y g r o u p : (a) The r e f e r r e d s u b j e c t h a d t o be a s s e s s e d by t h e M e n t a l H e a l t h Team a s r e q u i r i n g p s y c h i a t r i c c a r e as some c l i e n t s who a r e r e f e r r e d t o t h e team a r e a s s e s s e d as b e i n g i n a p p r o p r i a t e f o r v a r i o u s r e a s o n s , e . g . , d r u g and a l c o h o l p r o b l e m s . A l t h o u g h t h e t u r n i n g down o f a r e f e r r a l i s an i n t e r e s t i n g p r o c e s s i n i t s e l f , i t d o e s n o t a l l o w f o r t h e i n v e s t i g a t i o n t o go on i f t h e c l i e n t i s n o t f o l l o w e d by t h e team. (b) The c l i e n t h a d t o be 65 y e a r s o f age o r o l d e r a t t h e t i m e o f r e f e r r a l . T h r o u g h t h i s method t h e n , a s a mple o f f i v e r e f e r r e d c l i e n t s was g a t h e r e d t o i n v e s t i g a t e t h e p r o c e s s o f t h e i r r e f e r r a l t o t h e M e n t a l H e a l t h Team t h r o u g h u n s t r u c t u r e d i n t e r v i e w s and p a r t i c i p a n t o b s e r v a t i o n . A c a s e s t u d y a p p r o a c h was s e l e c t e d b e c a u s e o f t h e e x p l o r a t o r y n a t u r e o f t h e i n v e s t i g a t i o n . The u s e o f t h i s a p p r o a c h a l l o w e d t h e i n v e s t i g a t o r t o f o r m u l a t e more p r e c i s e c o n c e p t s and h y p o t h e s e s r e l e v a n t t o f u r t h e r r e s e a r c h on t h e s o c i a l c o n t r o l o f m e n t a l i l l n e s s . The c a s e h i s t o r i e s o f a l l f i v e s u b j e c t s w i l l be d e s c r i b e d i n C h a p t e r T h r e e . R e f e r r a l Forms A n a l y s i s An i n c l u s i v e sample o f r e f e r r a l f o r m s f r o m e l d e r l y c l i e n t s r e f e r r e d t o t h e team between 1986 and 1987 was 36 s e l e c t e d and t a b u l a t e d by age, g e n d e r , r e a s o n o f r e f e r r a l and r e f e r r i n g a g e n t s . T h i s document r e v i e w p r o v i d e d a more " q u a l i t a t i v e " a n a l y s i s t o t h e s t u d y o f t h e r e f e r r a l p r o c e s s and s e r v e d t o i d e n t i f y w i t h more p r e c i s i o n who r e f e r s t h e e l d e r l y t o t h e team and f o r what p u r p o s e . D a t a o b t a i n e d f r o m t h i s a n a l y s i s w i l l be o u t l i n e d i n C h a p t e r T h r e e . U n s t r u c t u r e d I n t e r v i e w The o t h e r s t r a t e g y o f d a t a c o l l e c t i o n was u n s t r u c t u r e d i n t e r v i e w s o f k e y i n f o r m a n t s i d e n t i f i e d d u r i n g d i r e c t o b s e r v a t i o n o f t h e v a r i o u s e v e n t s r e l a t e d t o t h e r e f e r r a l o f e l d e r l y c l i e n t s i n t h e c a s e s t u d y s a m p l e . T h e s e i n f o r m a n t s were i d e n t i f i e d by t h e i m p o r t a n c e o f t h e i r r o l e i n i d e n t i f y i n g , a s s e s s i n g and r e f e r r i n g t h e s u b j e c t s . Some key i n f o r m a n t s were s t a f f f r o m t h e team o r s t a f f f r o m t h e r e f e r r i n g a g e n c i e s a n d / o r i n s t i t u t i o n s . F i n a l l y , e a c h o f t h e . f i v e e l d e r l y p e r s o n s i n t h e c a s e s t u d y s a m p l e were a l s o i n t e r v i e w e d i n t h i s way. The i n t e r v i e w s r e m a i n e d u n s t a n d a r d i z e d b e c a u s e e a c h o f t h e r e s p o n d e n t s d i f f e r e d on t h e i r v a l u e s , b e l i e f s and k n o w l e d g e a r o u n d m e n t a l i l l n e s s and t h e e l d e r l y . I t was i m p o r t a n t t h a t I be s e n s i t i v e t o t h o s e d i f f e r e n c e s t o e x p l o r e e a c h r e s p o n d e n t ' s f i e l d o f e x p e r i e n c e . I t i s d i f f i c u l t t o a s k a c o n f u s e d e l d e r l y p e r s o n t h e same q u e s t i o n s t h a t I w o u l d a s k h i s o r h e r p s y c h i a t r i s t . I t was a more f l e x i b l e f o r m o f d a t a c o l l e c t i o n t a i l o r e d t o t h e n e e d s o f t h e s u b j e c t s i n t h e s t u d y . 37 A l l i n t e r v i e w s were t a p e d and t h e i r c o n t e n t t r a n s c r i b e d i n f u l l t o m a x i m i z e t h e a c c u r a c y o f t h e d a t a . F u r t h e r m o r e , d u r i n g t h e i n t e r v i e w , I a l s o t o o k n o t e s t o h i g h l i g h t t h e key p o i n t s made by t h e i n f o r m a n t s . The c o n t e n t o f t h e i n t e r v i e w s was a n a l y z e d f o l l o w i n g t r a n s c r i p t i o n i n an i n d u c t i v e f a s h i o n t o a l l o w p a t t e r n s , themes, and c a t e g o r i e s o f a n a l y s i s t o emerge a r o u n d t h e g l o b a l theme o f t h e s o c i a l c o n t r o l o f m e n t a l i l l n e s s . P a r t i c i p a n t O b s e r v a t i o n P a r t i c i p a n t o b s e r v a t i o n h e r e r e f e r s t o a method i n w h i c h t h e r e s e a r c h e r i s p a r t o f and p a r t i c i p a t e s i n t h e a c t i v i t i e s o f t h e p e o p l e , g r o u p o r s i t u a t i o n t h a t i s b e i n g s t u d i e d . The m a j o r i s s u e i n t h e u s e o f t h i s method i s how much o f a p a r t i c i p a n t s h o u l d t h e r e s e a r c h e r be i n a p a r t i c u l a r s i t u a t i o n . The e m p h a s i s i n t h i s s t u d y was on t h e r e s e a r c h e r p a r t i c i p a t i n g i n t h e s i t u a t i o n n e e d i n g o b s e r v a t i o n . T h i s p a r t i c i p a t i o n o c c u r r e d a t two l e v e l s . F i r s t l y , I t o o k on an " a c t i v e " p a r t i c i p a t i o n by a c t u a l l y p e r f o r m i n g numerous s t a f f f u n c t i o n s s u c h a s a s s e s s m e n t s o r c o u n s e l l i n g . S e c o n d l y , i n t h e s p e c i f i c c a s e s t u d i e s s e l e c t e d f o r t h i s i n v e s t i g a t i o n , I t o o k on a " p a s s i v e " p a r t i c i p a t i o n r o l e where I o b s e r v e d what was h a p p e n i n g w i t h o u t d i r e c t l y i n v o l v i n g m y s e l f i n t h e o n g o i n g p r o c e s s , e .g., I w o u l d s i t t h r o u g h an a s s e s s m e n t i n t e r v i e w o r a c o u n s e l l i n g s e s s i o n . F i e l d n o t e s were t h e f a v o r e d method o f d a t a c o l l e c t i o n d u r i n g t h e o b s e r v a t i o n p e r i o d s . T h ey p r o v i d e d me w i t h a 38 d e t a i l e d and d e s c r i p t i v e a c c o u n t o f t h e o b s e r v a t i o n s I made d u r i n g any g i v e n p e r i o d o f t i m e . T h i s method i n c l u d e d f i v e e l e m e n t s o f d e s c r i p t i o n a s o u t l i n e d b y L o f l a n d ( 1 9 7 1 ) : (1) A r u n n i n g d e s c r i p t i o n t o r e c o r d a c c u r a t e l y t h e c o n c r e t e e v e n t s t h a t a r e o b s e r v e d . (2) P r e v i o u s l y f o r g o t t e n h a p p e n i n g s t h a t may be r e c a l l e d w h i l e s t i l l i n t h e f i e l d . (3) A n a l y t i c a l i d e a s and i n f e r e n c e s . (4) P e r s o n a l i m p r e s s i o n s and f e e l i n g s . (5) N o t e s f o r f u r t h e r i n f o r m a t i o n . A l l o f t h e above e l e m e n t s were g a t h e r e d i n t h e f i e l d e i t h e r by h a n d w r i t t e n n o t e s o r t h e y were r e c o r d e d on a u d i o t a p e and t r a n s c r i b e d l a t e r on. F I E L D STRATEGY As a p a r t i c i p a n t - o b s e r v e r , I was f u l l y e n g a g e d i n e x p e r i e n c i n g t h e s e t t i n g u n d e r s t u d y t h r o u g h b o t h o b s e r v a t i o n s and d i r e c t c o n t a c t w i t h t h e v a r i o u s i n d i v i d u a l s b e i n g o b s e r v e d . T h i s i m m e r s i o n i n t h e f i e l d was made p o s s i b l e b e c a u s e o f my p o s i t i o n a s a f i e l d work s t u d e n t a t t h e community m e n t a l h e a l t h team. T h i s p o s i t i o n e n t a i l e d t h a t t w i c e w e e k l y , I p a r t i c i p a t e d i n a l l o f t h e team's n o r m a l s t a f f a c t i v i t i e s f o r a p e r i o d o f n i n e months between O c t o b e r , 1988 and J u n e , 1989. T h e s e a c t i v i t i e s i n c l u d e d i n t a k e i n t e r v i e w s o f r e f e r r e d c l i e n t s , a s s e s s m e n t o f c l i e n t s ' " p s y c h i a t r i c " p r o b l e m s a l o n g w i t h team p s y c h i a t r i s t s , c o u n s e l l i n g o f a s m a l l 39 c a s e l o a d o f c l i e n t s and o u t r e a c h v i s i t s t o community f a c i l i t i e s . T h i s p o s i t i o n a l s o a l l o w e d me t o o b s e r v e t h e team's s t a f f i n t h e p e r f o r m a n c e o f t h e i r v a r i o u s f u n c t i o n s . My c o n t i n u o u s p r e s e n c e a t t h e team o v e r a n i n e month p e r i o d a l s o a l l o w e d t h e s t a f f t o f a m i l i a r i z e t h e m s e l v e s w i t h my p r e s e n c e t o t h e p o i n t where I f e l t i n t e g r a t e d t o t h e team somewhat l i k e a p a r t - t i m e e m p l o y e e . A t r u s t i n g r e l a t i o n s h i p d e v e l o p e d b e t w e e n m y s e l f and t h e s t a f f , w h i c h was s m a l l i n number ( t e n f u l l t i m e t h e r a p i s t s and s i x s e s s i o n a l p s y c h i a t r i s t s ) . As a f i e l d s t u d e n t I was a s s i g n e d t o one o f t h e t h e r a p i s t s t o be s u p e r v i s e d b y him. I was a b l e t o d e v e l o p a t r u s t w o r t h y w o r k i n g r e l a t i o n s h i p w i t h him. T h e r e was a m u t u a l r e s p e c t f o r e a c h o t h e r ' s work a s t h e r a p i s t s t h a t d e v e l o p e d w i t h i n t h e f i r s t few months o f my s t a r t a t t h e team. S e c o n d l y , a s i m i l a r t r u s t a l b e i t n o t as i n t e n s e , was b u i l t w i t h t h e o t h e r w o r k e r s whom I made an e f f o r t t o g e t t o know on a p e r s o n a l b a s i s t h r o u g h v a r i o u s team a c t i v i t i e s , e .g., i n t a k e c o n f e r e n c e , b u t a l s o t h r o u g h v a r i o u s e x t r a -c u r r i c u l a r a c t i v i t i e s , e .g., s t a f f p a r t i e s , l u n c h e o n s . T h i s i n t i m a t e i n v o l v e m e n t o f t h e r e s e a r c h e r w i t h team a c t i v i t i e s r a i s e s q u e s t i o n s r e g a r d i n g t h e v a l i d i t y o f t h e d a t a . S u p p o r t f o r t h i s a p p r o a c h c a n be g a t h e r e d by r e v i e w i n g t h e d e b a t e i n t h e f i e l d o f e t h n o g r a p h y between p r o p o n e n t s o f t h e n a t u r a l i s t i c a p p r o a c h and p r o p o n e n t s o f t h e r e f l e x i v e a p p r o a c h . N a t u r a l i s m p r o p o s e s t h a t a s f a r a s p o s s i b l e , t h e s o c i a l w o r l d s h o u l d be s t u d i e d i n i t s n a t u r a l s t a t e 40 u n d i s t u r b e d by t h e r e s e a r c h e r . T h i s a p p r o a c h p o s e s a number o f r e q u i r e m e n t s . F i r s t , t h e r e s e a r c h e r must r e m a i n t r u e t o t h e phenomenon u n d e r s t u d y r a t h e r t h a n t o any p a r t i c u l a r s e t o f m e t h o d o l o g i c a l p r i n c i p l e s . S e c o n d l y , n a t u r a l i s m a d v a n c e s t h a t i t i s p o s s i b l e t o c o n s t r u c t an a c c o u n t o f t h e c u l t u r e u n d e r i n v e s t i g a t i o n t h a t c a p t u r e s i t as e x t e r n a l t o , and i n d e p e n d e n t o f t h e r e s e a r c h e r . U n d e r t h i s r e q u i r e m e n t t h e n , t h e d e s c r i p t i o n o f a c u l t u r e becomes t h e p r i m a r y g o a l . What i s f a v o r e d t h e n a r e d e t a i l e d d e s c r i p t i o n s o f t h e c o n c r e t e e x p e r i e n c e s o f l i f e w i t h i n t h a t c u l t u r e and what i s d i s c o u r a g e d a r e a t t e m p t s t o go b e y o n d d e s c r i p t i o n s t o e x t r a p o l a t e m e a n i n g s w h i c h c o u l d be g e n e r a l i z e d a c r o s s c u l t u r e s . A l t h o u g h t h e n a t u r a l i s t i c way o f d o i n g r e s e a r c h p o i n t s t o t h e d a n g e r o f m a k i n g s w e e p i n g i n f e r e n c e s and a s s u m p t i o n s a b o u t t h e c u l t u r e b e i n g o b s e r v e d , i t f a i l s t o r e c o g n i z e t h a t a l l r e s e a r c h by v i r t u e o f u s i n g a method, i n v o l v e s s e l e c t i o n and i n t e r p r e t a t i o n . I n some way, t h e r e i s an e m p i r i c a l p o s i t i v i s t i c n o t i o n embedded i n n a t u r a l i s m t h a t t h e w o r l d c a n be s t u d i e d o b j e c t i v e l y by r e p l a c i n g t h e m i c r o s c o p e w i t h f i e l d n o t e s . B o t h p o s i t i v i s m and n a t u r a l i s m seemed t o be o b s e s s e d w i t h e l i m i n a t i n g t h e e f f e c t s o f t h e r e s e a r c h e r on t h e d a t a by t u r n i n g h i m / h e r i n t o "an a u t o m a t i o n and a n e u t r a l v e s s e l o f c u l t u r a l e x p e r i e n c e " (Hammersley and A t k i n s o n , 1983, p . 1 4 ) . A n a t u r a l i s t i c a p p r o a c h a l s o i g n o r e s t h e f a c t t h a t t h e r e s e a r c h e r i s p a r t o f t h e s o c i a l w o r l d h e / s h e s t u d i e s and 41 t h e r e f o r e , c a n n o t a v o i d m a k i n g some i m p a c t on i t by s t u d y i n g i t . A r e f l e x i v e a p p r o a c h on t h e o t h e r hand p r o p o s e s t h a t t h e r e s e a r c h e r ' s i m p a c t on t h e c u l t u r e and h i s / h e r r e a c t i o n t o i t a r e v a l u a b l e s o u r c e s o f d a t a w h i c h s h o u l d be e x p l o i t e d r a t h e r t h a n e l i m i n a t e d . I n o t h e r words, s o c i a l r e s e a r c h i s n o t j u s t o b s e r v a t i o n . I t i s a l s o p a r t i c i p a n t - o b s e r v a t i o n w h i c h means t h e r e s e a r c h e r b e i n g p a r t o f t h e w o r l d o b s e r v e d , and r e f l e c t i n g on t h a t p a r t i c i p a t i o n . T h i s phenomenon i s r e f e r r e d t o b y Hammersley and A t k i n s o n ( I b i d ) a s r e f l e x i v i t y . I f t h e r e s e a r c h e r h a s an i m p a c t on t h e w o r l d h e / s h e i s i n v e s t i g a t i n g , n o t t o document s u c h i m p a c t w o u l d u n d e r m i n e t h e c o m p l e t e n e s s o f t h e s t u d y . T h i s p a r a d i g m was i m p o r t a n t f o r t h e way e t h n o g r a p h i c r e s e a r c h was u s e d i n t h i s s t u d y . The n a t u r a l i s t i c model o f i n v e s t i g a t i o n p r o v e d t o be an i n a d e q u a t e a p p r o a c h t o b e s t a n s wer my r e s e a r c h q u e s t i o n s w h i l e a c c o u n t i n g f o r my p o s i t i o n a s a f i e l d work s t u d e n t w i t h i n t h e M e n t a l H e a l t h Team. I t n e g l e c t e d t h e f u n d a m e n t a l n o t i o n o f r e f l e x i t i v i t y , t h e f a c t t h a t t h e r e s e a r c h e r i s p a r t o f t h e w o r l d s h e / h e s t u d i e s . As Hammersley and A t k i n s o n (1983) p u t i t , ". . . A l l s o c i a l r e s e a r c h i s f o u n d e d on t h e human c a p a c i t y f o r p a r t i c i p a n t o b s e r v a t i o n . We a c t i n t h e s o c i a l w o r l d and y e t a r e a b l e t o r e f l e c t upon o u r s e l v e s and o u r a c t i o n s as o b j e c t s i n t h a t w o r l d . By i n c l u d i n g o u r own r o l e w i t h i n t h e r e s e a r c h f o c u s and s y s t e m a t i c a l l y e x p l o i t i n g o u r p a r t i c i p a t i o n i n t h e w o r l d u n d e r s t u d y as r e s e a r c h e r s we c a n d e v e l o p and t e s t t h e o r y w i t h o u t p l a c i n g r e l i a n c e on f u t i l e a p p e a l s t o t e n e t s o f e i t h e r p o s i t i v i s t o r n a t u r a l i s t v a r i e t i e s , (p. 25) 42 T h i s s t a t e m e n t was most r e l e v a n t t o my d u a l p o s i t i o n w i t h i n t h e team a s b o t h a r e s e a r c h e r and a f i e l d work s t u d e n t . W i t h i n t h e p o s i t i v i s t i c / n a t u r a l i s t i c framework, my p o s i t i o n a s a r e s e a r c h e r w o u l d h a v e i r r e v o c a b l y c o m p r o m i s e d my d a t a b e c a u s e o f my i n v o l v e m e n t a s a s t u d e n t n e e d i n g t o do w e l l i n h i s p l a c e m e n t t o p a s s h i s c o u r s e . No l o n g e r was I a n e u t r a l o b s e r v e r o f t h e phenomenon I was s t u d y i n g . My o b s e r v a t i o n s w o u l d h a v e b e e n so b i a s e d t h a t my f i n d i n g s w o u l d be i n v a l i d a t e d . My argument i s however, l i k e Hammersley and A t k i n s o n , t h a t b e i n g a s t u d e n t a t t h e team and p e r f o r m i n g many o f t h e d u t i e s done by t h e s t a f f and a l s o g e t t i n g t o know them on a p e r s o n a l b a s i s a l l o w e d me t o g a i n i n s i g h t and an u n d e r s t a n d i n g o f t h e i r s o c i a l w o r l d w h i c h w o u l d have b e e n u n a v a i l a b l e t o me as a n e u t r a l r e s e a r c h e r l o o k i n g i n f r o m t h e o u t s i d e . I e x p l o i t e d t h i s p o s i t i o n t o make more c o m p l e t e o b s e r v a t i o n s o f t h e p r o c e s s e s I p a r t i c i p a t e d i n w h i l e t e a s i n g o u t d e l i c a t e i n f o r m a t i o n f r o m t h e i n d i v i d u a l s I i n t e r v i e w e d . F u r t h e r m o r e , a c t i n g somewhat l i k e a s t a f f member, I was a b l e t o p u t m y s e l f t h r o u g h s i m i l a r s i t u a t i o n s t h a t t h e y e x p e r i e n c e d and n o t e my own r e a c t i o n s t o them. How d i d i t f e e l t o i n t e r v i e w an e l d e r l y p e r s o n ; what i s e x p e c t e d o f me when I a s s e s s e d t h a t p e r s o n ; how do I d e a l w i t h t h e n u r s i n g home s t a f f who want t h i s p e r s o n c o m m i t t e d t o a m e n t a l i n s t i t u t i o n ; what k i n d o f p r e s s u r e do t h e y p u t on me and how do I r e a c t a s a m e n t a l h e a l t h p r o f e s s i o n a l ; a r e t h e k i n d o f s i t u a t i o n s I e n c o u n t e r and t h e k i n d o f r e a c t i o n s I h a v e s i m i l a r o r d i f f e r e n t f r o m my 43 c o l l e a g u e s ; e t c . . .? O v e r a l l , t h e n , t h e o p p o r t u n i t y I had o f i n t e g r a t i n g m y s e l f a s a r e s e a r c h e r w i t h i n t h e Team a l l o w e d me t o i n c r e a s e t h e d e p t h and r i c h n e s s o f my d a t a . T h i s i s i l l u s t r a t e d by the- f o l l o w i n g a n e c d o t e : a p s y c h i a t r i s t was d i s c u s s i n g w i t h me h i s r a d i c a l a n t i - p s y c h i a t r i s t v i e w s , and s a i d i f what he had t o l d me was t o become common knowledge, he w o u l d be i n d eep t r o u b l e . METHODOLOGICAL CONSIDERATIONS In t h i s s e c t i o n I w i l l d i s c u s s how I a d d r e s s e d t h e t h r e a t s t o r e l i a b i l i t y and v a l i d i t y o f my f i n d i n g s i n r e l a t i o n s h i p t o t h e m e t h o d o l o g y I s e l e c t e d f o r t h i s s t u d y . I s s u e s o f R e l i a b i l i t y A s s e s s i n g t h e i n t e r n a l r e l i a b i l i t y o f o b s e r v a t i o n a l r e s e a r c h i s a d i f f i c u l t i s s u e f o r t h i s s t u d y . B e c a u s e I was t h e o n l y r e s e a r c h e r o b s e r v i n g t h e i n d i v i d u a l s and g r o u p s s t u d i e d , t h e r e a r e m i n i m a l ways i n w h i c h t o a s s e s s t h e i n t e r n a l r e l i a b i l i t y o f my f i e l d n o t e s . However, t h r o u g h o u t t h e r e s e a r c h I d i d g e t " f e e d b a c k " f r o m k e y i n f o r m a n t s t o v e r i f y p e r s o n a l o b s e r v a t i o n s on c e r t a i n e v e n t s , e.g., an a s s e s s m e n t i n w h i c h t h e y were i n v o l v e d . F u r t h e r m o r e , I compared d a t a o b t a i n e d f r o m p a r t i c i p a n t o b s e r v a t i o n w i t h d a t a o b t a i n e d f r o m my i n t e r v i e w s and c h a r t r e v i e w . Hence, a c c o r d i n g t o D e n z i n (1978) t h e s t r e n g t h o f t h i s a p p r o a c h i s b a s e d on t h e p r e m i s e t h a t : 44 no s i n g l e method e v e r a d e q u a t e l y s o l v e s t h e p r o b l e m o f r i v a l c a u s a l f a c t o r s . . . B e c a u s e e a c h method r e v e a l s d i f f e r e n t a s p e c t s o f e m p i r i c a l r e a l i t y , m u l t i p l e methods o f o b s e r v a t i o n s must be employed, (p. 28) T h e r e f o r e , c o m p r i s i n g d a t a s e r v e d t o i n c r e a s e t h e i n t e r n a l r e l i a b i l i t y o f my f i n d i n g s . T h r e a t s t o e x t e r n a l r e l i a b i l i t y were a l s o a d d r e s s e d i n d e s i g n i n g t h i s s t u d y . An e t h n o g r a p h i c s t u d y u n l i k e an e x p e r i m e n t c a n n o t be r e p l i c a t e d w i t h e x a c t i t u d e . E t h n o g r a p h y i s a s t u d y o f t h e p r o c e s s o f c h a n g e w i t h i n a g i v e n c u l t u r e , and t h e r e f o r e d o e s n o t l e n d i t s e l f t o e x a c t r e p l i c a t i o n b e c a u s e " n a t u r a l " r e a l i t y c a n n o t be c o n t r o l l e d i n an e x p e r i m e n t a l way (LeCompte and G o e t z , 1 9 8 2 ) . However, t h i s r e p l i c a t i o n p r o b l e m was p a r t l y a d d r e s s e d by c l e a r l y i n d i c a t i n g t h e methods u s e d and d e s c r i b i n g w i t h s p e c i f i c i t y t h e d e s i g n o f t h e s t u d y . F u r t h e r m o r e , t h e r e s e a r c h e r ' s s t a t u s p o s i t i o n w i t h i n t h e M e n t a l H e a l t h Team, t h e c h o i c e o f k e y i n f o r m a n t s , t h e s o c i a l and i n t e r p e r s o n a l c o n t e x t s i n w h i c h t h e d a t a was c o l l e c t e d were c l e a r l y d e s c r i b e d . E s s e n t i a l l y , t h e n , o t h e r r e s e a r c h e r s w a n t i n g t o r e p l i c a t e t h i s s t u d y c o u l d u s e t h i s r e p o r t a s an o p e r a t i n g m a n u a l. I s s u e s o f V a l i d i t y The c o n c e p t o f v a l i d i t y r e l a t e s t o w h e t h e r r e s e a r c h e r s a c t u a l l y o b s e r v e what t h e y t h i n k t h e y a r e o b s e r v i n g o r i n t h e c a s e o f t h i s s t u d y , how a c c u r a t e l y am I l o o k i n g a t t h e c o n t r o l o f m e n t a l i l l n e s s w i t h i n a g i v e n c u l t u r e . 45 C o n t e n t V a l i d i t y C o n t e n t o r f a c e v a l i d i t y i n v o l v e s a s s e s s i n g w h e t h e r t h e r e i s a l o g i c a l r e l a t i o n s h i p b etween t h e v a r i a b l e and t h e measure u s e d . E t h n o g r a p h i c r e s e a r c h h a s a number o f m e t h o d o l o g i c a l l i m i t a t i o n s i n r e g a r d s t o c o n t e n t v a l i d i t y . As M o n e t t e (1986) p o i n t s o u t , o b s e r v a t i o n r e s t s on human s e n s e o r g a n s and human p e r c e p t i o n s b o t h o f w h i c h c a n be s t r o n g s o u r c e s o f b i a s . However, o b s e r v a t i o n a l t e c h n i q u e s s u c h a s p a r t i c i p a n t -o b s e r v a t i o n d e m o n s t r a t e a g r e a t e r c o n t e n t v a l i d i t y a s m e a s u r e s o f b e h a v i o r s and e v e n t s t h a n do many o t h e r t e c h n i q u e s r e l y i n g on s e c o n d h a n d a c c o u n t s . F o r example, s u r v e y s and q u e s t i o n n a i r e s d e p e n d on someone e l s e ' s p e r c e p t i o n and r e c o l l e c t i o n , t h a t o f t h e r e s p o n d e n t o r t h e p e r s o n c o m p l e t i n g t h e i n s t r u m e n t i n h i s o r h e r p l a c e . T h i s p r o c e s s i s a f f e c t e d by many f a c t o r s b e y o n d t h e c o n t r o l o f t h e r e s e a r c h e r . On t h e o t h e r hand, o b s e r v a t i o n t e c h n i q u e s p r o v i d e a f i r s t hand a c c o u n t o f e v e n t s a n d / o r b e h a v i o r s a s t h e y o c c u r . T h e r e f o r e , i f t h e r e s e a r c h e r i s i n a p o s i t i o n t o l e a s t i n f l u e n c e t h e s e e v e n t s by h i s o r h e r p r e s e n c e , t h e n what i s o b s e r v e d i s c l o s e s t t o r e a l i t y . A n o t h e r way o f a d d r e s s i n g t h e q u e s t i o n o f v a l i d i t y i s by l o o k i n g a t i t i n t e r m s o f i n t e r n a l and e x t e r n a l v a l i d i t y . I n t e r n a l V a l i d i t y P o s s i b l y t h e g r e a t e s t s t r e n g t h o f e t h n o g r a p h y i s i t s c l a i m t o h i g h i n t e r n a l v a l i d i t y . The r e s e a r c h e r ' s p r a c t i c e t o become p a r t o f t h e c u l t u r e s t u d i e d a s i t h a p p e n s and h i s o r 46 h e r a b i l i t y t o c o l l e c t d a t a f r o m i t s k e y i n f o r m a n t s e n s u r e s t h a t t h e d a t a c o l l e c t e d and t h e c o n s t r u c t s e x t r a c t e d f r o m i t a c t u a l l y r e f l e c t t h e r e a l i t y o f i t s p a r t i c i p a n t s ' e x p e r i e n c e . As d i s c u s s e d e a r l i e r my p o s i t i o n a s a s t u d e n t d o i n g a c l i n i c a l p r a c t i c u m w i t h i n t h e team a l l o w e d me t o f u l l y i n t e g r a t e m y s e l f a s a s t a f f member o v e r t h e n i n e month p e r i o d I was t h e r e , and p a r t i c i p a t e i n t h e i r r e a l i t y t o c o l l e c t v a l i d d a t a . A number o f t h r e a t s t o i n t e r n a l v a l i d i t y a s i d e n t i f i e d by C a m p b e l l and S t a n l e y (1963) were a l s o a d d r e s s e d i n t h i s s t u d y t o f u r t h e r s t r e n g t h e n i t s c l a i m t o h i g h i n t e r n a l v a l i d i t y w h i c h I w i l l d i s c u s s n e x t . H i s t o r y and M a t u r a t i o n The s t u d y s p a n n e d a p e r i o d o f n i n e months. T h e r e f o r e , t h e r a n g e o f e v e n t s and b e h a v i o r s o b s e r v e d o v e r t h a t p e r i o d o f t i m e c a n be assumed t o be r e a s o n a b l y r e p r e s e n t a t i v e o f t h e team's f u n c t i o n i n g o v e r l o n g e r p e r i o d s o f t i m e , and most l i k e l y c a n n o t be a t t r i b u t e d t o a s p e c i f i c s i t u a t i o n o c c u r r i n g d u r i n g t h e o b s e r v a t i o n a l p e r i o d . O b s e r v e r ' s E f f e c t The o b s e r v e r ' s e f f e c t r e l a t e s t o how t h e s u b j e c t s i n a s t u d y r e a c t t o t h e p r e s e n c e o f t h e r e s e a r c h e r . I n o t h e r w o rds, p e o p l e b e i n g o b s e r v e d may b e h a v e d i f f e r e n t l y t h a n n o r m a l l y b e c a u s e t h e y r e a c t t o t h e p r e s e n c e o f t h e o b s e r v e r . The o b s e r v e r ' s e f f e c t i n t h i s s t u d y was j u d g e d t o be m i n i m a l m a i n l y b e c a u s e o f my s t a t u s a s a member o f t h e M e n t a l 47 H e a l t h Team and b e c a u s e o f t h e g o od r e l a t i o n s h i p I e n t e r t a i n e d w i t h t h e team's s t a f f . I t was my i m p r e s s i o n t h a t t h e s t a f f d i d n o t p e r f o r m t h e i r f u n c t i o n s any d i f f e r e n t l y i n my p r e s e n c e d u r i n g o b s e r v a t i o n a l p e r i o d s . When d e a l i n g w i t h s u b j e c t s o u t s i d e o f t h e team, I f e l t t h a t i n t r o d u c i n g m y s e l f as a p r a c t i c u m s t u d e n t w i t h t h e M e n t a l H e a l t h Team was a d i s t i n c t a d v a n t a g e i n a c c e s s i n g k e y i n f o r m a n t s f o r t h e s t u d y . A l l i n t e r v i e w e d o r o b s e r v e d i n f o r m a n t s were most c o o p e r a t i v e i n p a r t i c i p a t i n g i n t h e s t u d y . A n o t h e r f o r m o f o b s e r v e r ' s e f f e c t c a n be f o u n d i n t h e way t h e r e s p o n d e n t s i n t h e s t u d y a r e a f f e c t e d by t h e i n t e r v i e w e r ' s c h a r a c t e r i s t i c s and i n v e r s e l y , how t h e i n t e r v i e w e r i s a f f e c t e d by t h e r e s p o n d e n t s ' c h a r a c t e r i s t i c s . Sex, age, r a c e , and s o c i a l c l a s s a r e f a c t o r s t h a t may s u b t l y s h a p e t h e way i n w h i c h t h e i n t e r v i e w e r a s k s q u e s t i o n s and i n t e r p r e t s t h e words o f r e s p o n d e n t s , and how r e s p o n d e n t s w i l l a nswer t h e s e q u e s t i o n s . I n t h e c a s e o f t h i s s t u d y , age was an o b v i o u s f a c t o r a s many o f t h e r e s p o n d e n t s were e l d e r l y . T h e s e s o c i o -d e m o g r a p h i c c h a r a c t e r i s t i c s a r e o b v i o u s l y n o t c o n t r o l l a b l e . However, a s a r e s e a r c h e r I d i d t e n d t o a h o s t o f " i n t e r v i e w e r b i a s " f a c t o r s s u c h as my t o n e o f v o i c e , manner, g e s t u r e s and d r e s s . My a p p r o a c h t o w a r d s e l d e r l y r e s p o n d e n t s was t o u s e a p o l i t e manner and I t o o k c a r e t o d r e s s i n a r e l a t i v e l y c o n s e r v a t i v e way. I d o u b t i f t h e e l d e r l y I i n t e r v i e w e d w o u l d h ave r e s p o n d e d as w e l l a s t h e y d i d w o u l d I h a v e w a l k e d i n d r e s s e d "Miami V i c e s t y l e " , w e a r i n g o l d f a d e d j e a n s and a T-s h i r t . I a l s o f a c i l i t a t e d t h e i n t e r v i e w p r o c e s s by e n g a g i n g 48 i n s m a l l t a l k t o p u t t h e i n t e r v i e w e e a t e a s e ; n o t a n s w e r i n g i m m e d i a t e l y a f t e r a r e p l y , t h u s e n c o u r a g i n g t h e i n t e r v i e w e e t o comment a t g r e a t e r l e n g t h ; n o t s h o w i n g s h o c k o r s u r p r i s e a t r e p l i e s ; l o o k i n g f o r e x a m p l e s when t h e r e p l i e s were t o o va g u e o r a b s t r a c t ; and t h e n u s i n g a p p r o p r i a t e p r o b i n g t o e l i c i t i n f o r m a t i o n w h i c h t h e r e s p o n d e n t h e l d c l o s e t o h i s / h e r c h e s t . P r o b i n g h e r e was u s e d c a r e f u l l y and w i t h t a c t a s t o o much p r o b i n g may be u n e t h i c a l and make t h e r e s p o n d e n t s u s p i c i o u s . S e l e c t i o n T h i s t h r e a t r e l a t e s t o t h e f a c t t h a t t h e d a t a c o l l e c t e d may be weakened by t h e i m p r o p e r s e l e c t i o n o f p a r t i c i p a n t s t o o b s e r v e and i n f o r m a n t s t o i n t e r v i e w . F o r t h i s s t u d y , k e y p a r t i c i p a n t s and i n f o r m a n t s were c a r e f u l l y s e l e c t e d t o be as r e p r e s e n t a t i v e a s p o s s i b l e o f t h e s t a f f and t h e i n s t i t u t i o n s i n v o l v e d i n t h e c o n t r o l o f m e n t a l i l l n e s s w i t h i n t h e e l d e r l y p o p u l a t i o n . F o r example, a r e f e r r e d c l i e n t f r o m a n u r s i n g home was s e l e c t e d a s a c a s e s t u d y b e c a u s e n u r s i n g homes make up a l a r g e p o r t i o n o f t h e r e f e r r a l s t o t h e team. A l l i n f o r m a n t s were s e l e c t e d on t h e b a s i s o f t h e i m p o r t a n c e o f t h e i r p a r t i c i p a t i o n w i t h i n t h e c a s e r e f e r r e d . F o r t h e above example, t h e team p s y c h i a t r i s t and p r i m a r y t h e r a p i s t were i n t e r v i e w e d and o b s e r v e d , a s w e l l a s t h e n u r s e f r o m t h e n u r s i n g home who made t h e r e f e r r a l and t h e n u r s i n g home o p e r a t o r who s a n c t i o n e d i t , a s w e l l a s t h e f a m i l y who was c o n s u l t e d i n t h i s c a s e . 49 E x t e r n a l V a l i d i t y The p r o b l e m o f e x t e r n a l v a l i d i t y r e l a t e s t o how t h e r e s e a r c h f i n d i n g s c a n be g e n e r a l i z e d t o t h e l a r g e r p o p u l a t i o n . E t h n o g r a p h i c r e s e a r c h c a n n o t r e l y on t h e s t r i c t u r e s o f s t a t i s t i c a l g e n e r a l i z a t i o n t o make a c l a i m t o e x t e r n a l v a l i d i t y a s r a r e l y a r e t h e p a r t i c i p a n t s o b s e r v e d o r i n t e r v i e w e d r a n d o m l y a s s i g n e d . I n f a c t , s u c h a p r o c e d u r e w o u l d be i r r e l e v a n t f o r most c a s e s . Le Compte and G o e t z (1982) t a l k o f s t r e n g t h e n i n g t h e e x t e r n a l v a l i d i t y o f e t h n o g r a p h i c f i n d i n g s by d e f i n i n g t h e t h r e a t s t h a t r e d u c e a s t u d y ' s c o m p a r a b i l i t y . The p r o b l e m o f c o m p a r a b i l i t y i s a d d r e s s e d m a i n l y by m u l t i s i t e e t h n o g r a p h i c d e s i g n s . A l t h o u g h t h e community M e n t a l H e a l t h Team was t h e c e n t r e o f t h e s t u d y , many o t h e r s i t e s were o b s e r v e d , s u c h as n u r s i n g homes, a s e n i o r h o u s i n g p r o j e c t , a p s y c h i a t r i c ward, e t c . Hence, t h i s m u l t i s i t e d e s i g n s e r v e d t o s t r e n g t h e n t h e g e n e r a l i z a b i l i t y o f t h e f i n d i n g s b y i n c r e a s i n g i t s c o m p a r a b i l i t y . 50 CHAPTER 3 RESEARCH SETTINGS AND DESCRIPTION OF SAMPLES T h i s c h a p t e r p r o v i d e s a d e s c r i p t i o n o f t h e community i n s t i t u t i o n s i n v o l v e d i n t h e r e f e r r a l t o t h e m e n t a l h e a l t h team o f e l d e r l y p e o p l e f r o m t h e c a s e s t u d y s a m p l e . E a c h o f t h e s e s u b j e c t s were o b s e r v e d i n t e r a c t i n g w i t h i n t h e s e i n s t i t u t i o n s a s w i l l a s w i t h i n t h e community m e n t a l h e a l t h team. A d e s c r i p t i o n o f t h e team i s a l s o i n c l u d e d . I n t e r v i e w s w i t h t h e s u b j e c t s and k e y i n f o r m a n t s w i t h i n t h e s e i n s t i t u t i o n s were a l s o c o n d u c t e d . F i n d i n g s f r o m t h e s e o b s e r v a t i o n s and i n t e r v i e w s a r e d i s c u s s e d i n c h a p t e r s f o u r and f i v e . S t a t i s t i c s f r o m t h e 1986 C e n s u s o f t h e p o p u l a t i o n o v e r 65 r e s i d i n g i n t h e team's g e n e r a l c a t c h m e n t a r e a a r e g i v e n a s t h e s a m p l i n g f r a m e f o r b o t h t h e c a s e s t u d y s a mple and f o r t h e r e f e r r a l f o r m s s a m p l e . D e m o g r a p h i c i n f o r m a t i o n o b t a i n e d f r o m t h e r e f e r r a l f o r m s f o r t h e . l a t t e r s a m p le was compared w i t h d a t a f r o m t h e C e n s u s . F i n a l l y , a d e s c r i p t i o n o f i n d i v i d u a l c a s e s t u d i e s i s i n c l u d e d a t t h e end o f t h e c h a p t e r . RESEARCH SETTING The f o l l o w i n g s e c t i o n i n c l u d e s a b r i e f d e s c r i p t i o n o f t h e i n s t i t u t i o n s w h i c h e i t h e r r e f e r r e d t h e f i v e e l d e r l y p e o p l e o r were c l o s e l y i n v o l v e d i n t h e r e f e r r a l p r o c e s s . A d e s c r i p t i o n o f t h e m e n t a l h e a l t h team i s a l s o i n c l u d e d . The i n s t i t u t i o n s 51 were i d e n t i f i e d by t y p e o n l y s o a s t o p r e s e r v e t h e a n o n y m i t y o f t h e s u b j e c t s and o f o t h e r i n d i v i d u a l s i n t e r v i e w e d a n d / o r o b s e r v e d d u r i n g t h e s t u d y . P s y c h i a t r i c Ward - G e n e r a l H o s p i t a l The ward w h i c h r e f e r r e d Mr. L. i s a 25 b e d a c u t e c a r e f a c i l i t y l o c a t e d w i t h i n a l a r g e g e n e r a l h o s p i t a l . N o r m a l l y a s h o r t s t a y u n i t , t h e l e n g t h o f t r e a t m e n t r a n g e s f r o m a few d a y s t o up t o t h r e e months. I t i s an open ward f a c i l i t y and t h e r e f o r e c a t e r s t o p a t i e n t s who a r e w i l l i n g t o s t a y f o r t r e a t m e n t and who do n o t d i s p l a y v i o l e n t b e h a v i o r . V i o l e n t and s e r i o u s l y d i s t u r b e d i n d i v i d u a l s a r e s e n t t o t h e p r o v i n c i a l f a c i l i t y f o r t r e a t m e n t . N u r s i n g Homes T h e s e a r e t h e f a c i l i t i e s w h i c h h a v e r e f e r r e d Mr. M. and M i s s S. Two c a s e s t u d y s u b j e c t s were s e l e c t e d f r o m two n u r s i n g homes b e c a u s e o f t h e i m p o r t a n c e o f t h i s s o u r c e o f r e f e r r a l t o t h e m e n t a l h e a l t h team. N u r s i n g home n u r s e s a r e r e p r e s e n t a t i v e s o f t h e s i n g l e l a r g e s t s o u r c e o f r e f e r r i n g a g e n t s , t h a t o f p r o f e s s i o n a l s w o r k i n g i n s e r v i c e s o t h e r t h a n m e n t a l h e a l t h . The n u r s i n g homes a l s o p o s s e s s e d q u i t e v a r i e d c h a r a c t e r i s t i c s . The home w h i c h r e f e r r e d Mr. M. was a l a r g e o v e r 100 b e d f a c i l i t y f u n d e d t h r o u g h a p r i v a t e non p r o f i t o r g a n i z a t i o n . The o t h e r one was a s m a l l e r 40 b e d f a c i l i t y a d m i n i s t e r e d and s t a f f e d by a r e l i g i o u s n u r s i n g o r d e r . 52 S o c i a l S e r v i c e A g e n c y The a g e n c y w h i c h r e f e r r e d M i s s D. i s a s m a l l f o u r s t a f f a g e n c y a d m i n i s t e r e d c o n j o i n t l y by M i n i s t r y o f H e a l t h and M i n i s t r y o f J u s t i c e r e p r e s e n t a t i v e s . The p u r p o s e o f t h e a g e n c y i s t o p r o v i d e f o l l o w - u p c a r e t o p a t i e n t s who a r e r e s i s t i v e t o t r e a t m e n t a n d / o r r e l u c t a n t t o f o l l o w mandated r e h a b i l i t a t i o n p r o g r a m s , e g . p r o b a t i o n o r d e r s f r o m b o t h m i n i s t r i e s . Community O r g a n i z a t i o n The o r g a n i z a t i o n w h i c h r e f e r r e d Mr. W. i s t h e c o n s t i t u e n c y o f f i c e o f one o f t h e m a j o r f e d e r a l p o l i t i c a l p a r t i e s . A l t h o u g h i t d o e s n o t o f f e r s e r v i c e s e x c l u s i v e l y t o t h e e l d e r l y , i t n e v e r t h e l e s s d e a l s w i t h them by h e a r i n g t h e i r c o m p l a i n t s , h e l p i n g them f i l l i n f o r m s , and s o on. A p a r t m e n t B u i l d i n g s No s p e c i f i c r e f e r r a l f r o m a p a r t m e n t b u i l d i n g s was s e l e c t e d a s t h r e e o u t o f f i v e c a s e s t u d i e s a l r e a d y r e s i d e d i n a p a r t m e n t b u i l d i n g s . I n two o f t h o s e c a s e s , t h e a p a r t m e n t managers were e x t e n s i v e l y i n v o l v e d w i t h b o t h c l i e n t s and t h e m e n t a l h e a l t h team, a l l o w i n g me t o make o b s e r v a t i o n s and c o n d u c t i n t e r v i e w s w i t h r e p r e s e n t a t i v e s o f t h a t g r o u p o f i m p o r t a n t r e f e r r i n g a g e n t s . 53 O t h e r I n s t i t u t i o n s O t h e r i n s t i t u t i o n s were a l s o o b s e r v e d a l t h o u g h n o t as e x t e n s i v e l y a s t h e above m e n t i o n e d i n s t i t u t i o n s . T h e s e i n c l u d e a p r o b a t i o n o f f i c e , a p r o v i n c i a l c o u r t , and a g e r i a t r i c s h o r t s t a y h o s p i t a l u n i t . Community M e n t a l ' H e a l t h Team The m a i n r e s e a r c h s e t t i n g o f t h i s s t u d y was t h e Community M e n t a l H e a l t h Team r e s p o n s i b l e f o r d e l i v e r i n g s e r v i c e s t o t h e p s y c h i a t r i c a l l y d i s a b l e d i n d i v i d u a l s i n t h e u r b a n c o r e . I n t h e n e x t few p a r a g r a p h s , I w i l l g i v e a b r i e f h i s t o r i c a l d e s c r i p t i o n o f t h e team, and d i s c u s s i t s f u n c t i o n a s o u t l i n e d i n i t s p o l i c y and p r o c e d u r e s m a n u a l . E a c h m e n t a l h e a l t h team was c r e a t e d f o r t h e p u r p o s e o f o f f e r i n g m e n t a l l y i l l i n d i v i d u a l s w i t h p s y c h i a t r i c f o l l o w - u p c a r e w h i l e l i v i n g i n t h e community e i t h e r i n d e p e n d e n t l y o r i n a r e s i d e n t i a l c a r e f a c i l i t y . M e n t a l h e a l t h teams a r e s c a t t e r e d t h r o u g h o u t t h e p r o v i n c e and d i s t r i b u t e t h e i r s e r v i c e s t o s p e c i f i c a d m i n i s t r a t i v e r e g i o n s u s u a l l y l o c a t e d a r o u n d l a r g e u r b a n c e n t r e s . Some m e n t a l h e a l t h teams a r e o p e r a t e d u n d e r g o v e r n m e n t j u r i s d i c t i o n w h i l e o t h e r s a r e r u n by a n o n - p r o f i t o r g a n i z a t i o n r e c e i v i n g f u n d s f r o m b o t h m u n i c i p a l and p r o v i n c i a l s o u r c e s . The M e n t a l H e a l t h Team d e s c r i b e d i n t h i s s t u d y comes u n d e r t h e a d m i n i s t r a t i o n o f t h e n o n - p r o f i t o r g a n i z a t i o n . T h i s o r g a n i z a t i o n h a s a t o t a l o f s i x teams r e s p o n s i b l e f o r d i s t r i b u t i n g s e r v i c e s i n v a r i o u s c a t c h m e n t a r e a s . A c c o r d i n g 54 t o i t s p o l i c y and p r o c e d u r e manual ( r e f e r e n c e w i t h h e l d f o r c o n f i d e n t i a l i t y p u r p o s e s ) e a c h team o f f e r s t h e f o l l o w i n g s e r v i c e s : (a) prompt p s y c h i a t r i c a s s e s s m e n t and d i a g n o s i s i n c l u d i n g v i s i t s i n t h e community i n emergency c i r c u m s t a n c e s . (b) c o m p r e h e n s i v e t r e a t m e n t may i n c l u d e p s y c h i a t r i c , m e d i c a t i o n s , i n d i v i d u a l , g r o u p and f a m i l y t h e r a p y , o c c u p a t i o n a l and r e c r e a t i o n a l t h e r a p y p r o g r a m s ( s e c t i o n 1 0 . 1 ) . A l l s e r v i c e s a r e p r o v i d e d w i t h a framework w h i c h s p e c i f i e s t h e f o l l o w i n g p r i n c i p l e : r e c o g n i z e s t h a t t h e s e r i o u s l y m e n t a l l y i l l a d u l t . . r e q u i r e s a b r o a d r a n g e o f s e r v i c e s and i s c o m m i t t e d t o u s i n g m u l t i -d i s c i p l i n a r y teams t o meet p a t i e n t n e e d s . ( S e c t i o n 2.1) Hence, e a c h m e n t a l h e a l t h team e m p l o y s a v a r i e t y o f p r o f e s s i o n a l s t o p r o v i d e m u l t i - d i s c i p l i n a r y s e r v i c e s t o t h e m e n t a l l y i l l . T h e s e i n c l u d e n u r s e s , p s y c h o l o g i s t s , s o c i a l w o r k e r s , o c c u p a t i o n a l t h e r a p i s t s , and p s y c h i a t r i s t s . S e r v i c e s w i t h i n t h e team a r e p r o v i d e d w i t h i n a g i v e n o r g a n i z a t i o n a l framework i n w h i c h t h e a b o v e p r o f e s s i o n a l s o c c u p y a g i v e n r o l e . E a c h p a t i e n t c o m i n g t o t h e team f o r t r e a t m e n t i s a s s i g n e d t o a p r i m a r y t h e r a p i s t w h i c h c a n be e i t h e r a n u r s e , p s y c h o l o g i s t , s o c i a l w o r k e r , o r o c c u p a t i o n a l t h e r a p i s t . The t h e r a p i s t ' s r o l e t h e n i s t o a s s e s s t h e p a t i e n t ' s p r o b l e m s and i n i t i a t e a t h e r a p e u t i c t r e a t m e n t p r o g r a m t h a t c a n i n c l u d e a s s e s s m e n t by a p s y c h i a t r i s t , 55 m e d i c a t i o n s , a c c e s s t o o t h e r community b a s e d s e r v i c e s , as w e l l a s r e f e r r a l t o a h o s p i t a l . W i t h i n t h a t framework, t h e p r i m a r y t h e r a p i s t d i r e c t s t h e t r e a t m e n t p r o g r a m and t h e p s y c h i a t r i s t a c t s a s a c o n s u l t a n t . E a c h m e n t a l h e a l t h team a c c e p t s r e f e r r a l s f r o m any s o u r c e i n c l u d i n g s e l f - r e f e r r a l s p r o v i d e d t h e r e i s an i n d i c a t i o n o f m e n t a l i l l n e s s i n t h e r e f e r r e d p e r s o n . F u r t h e r m o r e , p e o p l e a r e a c c e p t e d f o r r e f e r r a l o n l y i f t h e y a r e t r e a t a b l e i n a community s e t t i n g . Hence, i n d i v i d u a l s who a r e h o s p i t a l i z e d i n a p s y c h i a t r i c ward c a n n o t r e c e i v e team s e r v i c e s . The r e f e r r a l o f a p e r s o n t o a m e n t a l h e a l t h team i s a t w o f o l d p r o c e s s . F i r s t , an i n t a k e w o r k e r ( p r i m a r y t h e r a p i s t s a r e a s s i g n e d t o i n t a k e d u t i e s on a r o t a t i o n a l b a s i s ) t a k e s t h e r e f e r r a l by f i l l i n g o u t a s t a n d a r d i z e d f o r m w h i c h o u t l i n e s t h e n e e d e d i n f o r m a t i o n r e g a r d i n g a p a t i e n t ' s d e m o g r a p h i c s and p s y c h o p a t h o l o g y . The w o r k e r d e t e r m i n e s w h e t h e r t h e r e f e r r a l i s a t a f i r s t g l a n c e one w h i c h r e q u i r e s t h e team's i n v o l v e m e n t . A c c e p t e d r e f e r r a l s t h e n go t h r o u g h a s e c o n d s e l e c t i o n p r o c e s s where a l l r e f e r r a l s f r o m a g i v e n day a r e r e v i e w e d i n i n t a k e r o u n d s w h i c h o c c u r e v e r y m o r n i n g where a l l team s t a f f d e t e r m i n e t h e a p p r o p r i a t e n e s s o f e a c h r e f e r r a l . Once t h e r e f e r r a l s a r e deemed a p p r o p r i a t e , t h e y a r e a s s i g n e d t o an i n d i v i d u a l p r i m a r y t h e r a p i s t ' s c a s e l o a d . Once a p a t i e n t i s a s s i g n e d t o a t h e r a p i s t ' s c a s e l o a d , i t i s t h e n t h a t t h e r a p i s t ' s r e s p o n s i b i l i t y t o c o n t a c t t h e p a t i e n t , i n i t i a t e t r e a t m e n t , and a l s o t e r m i n a t e i t . F i n a l l y , p a r t i c u l a r t o t h e m e n t a l h e a l t h team i n v e s t i g a t e d i n t h i s s t u d y was t h e a s s i g n m e n t o f a p r i m a r y t h e r a p i s t t o t h e p o s i t i o n o f g e r i a t r i c s p e c i a l i s t . T h i s a s s i g n m e n t came a b o u t due t o t h e l a r g e number o f e l d e r l y p e r s o n s r e f e r r e d t o t h e team and t h e s p e c i f i c t r e a t m e n t m o d a l i t i e s t h e y p r e s e n t e d w h i c h were deemed t o be q u i t e d i f f e r e n t f r o m t h a t o f a y o u n g e r a d u l t p o p u l a t i o n and h e n c e r e q u i r i n g a c e r t a i n e x p e r t i s e f r o m t h e t h e r a p i s t ' s p a r t . T y p i c a l l y , most r e f e r r a l s o f i n d i v i d u a l s o v e r t h e age o f 65 were a s s i g n e d t o t h i s s p e c i a l i s t , and some were d e a l t w i t h by a n o t h e r t h e r a p i s t who a l t h o u g h n o t a g e r i a t r i c i a n t o o k a s p e c i a l i n t e r e s t i n t h e e l d e r l y . SAMPLING FRAME The i n f o r m a t i o n r e g a r d i n g t h e s a m p l i n g f r a m e was o b t a i n e d f r o m t h e 1986 C e n s u s ( S t a t i s t i c s Canada, 1 9 8 6 ) . The C e nsus t r a c t s f o r t h e V a n c o u v e r a r e a were s e l e c t e d b e c a u s e t h e y were u s e d b y t h e m e n t a l h e a l t h s o c i e t y t o d e t e r m i n e t h e c a t c h m e n t a r e a s e r v i c e d by team i n v e s t i g a t e d i n t h i s s t u d y . T h e r e f o r e t h e p o p u l a t i o n c h a r a c t e r i s t i c s o u t l i n e d b e l o w a r e r e p r e s e n t a t i v e o f t h e e l d e r l y p o p u l a t i o n a c c e s s e d by t h e team. The f o l l o w i n g p o p u l a t i o n c h a r a c t e r i s t i c s were s e l e c t e d : number o f m a l e s & f e m a l e s between a g e s 65-74; number o f m a l e s & . f e m a l e s a g e s 75 and a b o v e ; t y p e o f d w e l l i n g s ; and number o f f a m i l y v s . n o n - f a m i l y p e r s o n s . The p o p u l a t i o n d a t a i s s u m m a r i z e d i n T a b l e 1. 57 Table I 1986 Census Tract Data N % T o t a l p o p u l a t i o n ( a l l age c a t e g o r i e s ) : 42,964 100 T o t a l p o p u l a t i o n , 65 y e a r s and o v e r : 6,900 16 Population C h a r a c t e r i s t i c s by Age and Sex M a l e F e m a l e M a l e & Female N % N % N % 65-74 y e a r s 1870 (27) 1940 (28) 3810 (55) 75 y e a r s and o v e r 880 (13) 2210 (32) 3090 (45) T o t a l P o p u l a t i o n : 2750 (40) 4150 (60) 6900 (100) ( B o t h age c a t e g o r i e s ) Dwellings C h a r a c t e r i s t i c s and Types - A l l Age Groups C h a r a c t e r i s t i c s N % Owned 2,42 5 8 R e n t e d 27.115 92 T o t a l 29,540 100 T y p e s S i n g l e d e t a c h e d h o u s e 145 11 A p a r t m e n t , 5 s t o r e y s o r more 21,385 72 O t h e r d w e l l i n g t y p e 7,975 27 ( i n c l u d e s s e m i - d e t a c h e d h o u s e s , a p a r t m e n t i n a b u i l d i n g w i t h l e s s t h a n 5 s t o r e y s , row h o u s e , a p a r t m e n t o r f l a t i n a d e t a c h e d d u p l e x , o t h e r s i n g l e a t t a c h e d h o u s e T o t a l 29,540 100 Family Status - 65 Years and Over N % L i v i n g i n a f a m i l y s i t u a t i o n 2,120 31 L i v i n g w i t h r e l a t i v e s 265 4 L i v i n g w i t h n o n - r e l a t i v e s 125 2 L i v i n g a l o n e 4,390 63 T o t a l 6,900 100 58 The C e n s u s d a t a r e v e a l s t h a t t h e p o p u l a t i o n o v e r 65 y e a r s o f age makes f o r 16 p e r c e n t o f the- t o t a l p o p u l a t i o n f o r t h a t a r e a . O v e r a l l , t h e r e a r e more women t h a n men o v e r t h e age 65 (60% v s 40%) . T h i s i s e s p e c i a l l y p r e v a l e n t i n t h e o l d e r age g r o u p o v e r 75 y e a r s (32% v s 1 3 % ) . S i x t y - t h r e e p e r c e n t o f a l l e l d e r l y l i v e a l o n e . T h e r e a r e no s p e c i f i c d a t a a v a i l a b l e f r o m t h e C e n s u s i n r e g a r d s t o t h e d w e l l i n g s e l d e r l y p e o p l e r e s i d e i n . However, d a t a f o r t h e g e n e r a l p o p u l a t i o n i n d i c a t e s t h a t most r e s i d e n t s r e n t t h e i r d w e l l i n g i n a p r o p o r t i o n o f 92 p e r c e n t , w h i c h i s i n 72 p e r c e n t o f t h e c a s e s , an a p a r t m e n t i n a b u i l d i n g o v e r f i v e s t o r e y s . B e c a u s e o f t h e i r l o w e r s o c i o - e c o n o m i c s t a t u s , t h e e l d e r l y g e n e r a l l y b e l o n g t o t h e l e s s a f f l u e n t c l a s s e s and t h e r e f o r e a r e i n a more v u l n e r a b l e p o s i t i o n t o be l a b e l l e d a s m e n t a l l y i l l . From t h e C e n s u s d a t a , one c o u l d s p e c u l a t e t h a t t h e e l d e r l y p o p u l a t i o n o f t h e s a m p l i n g f r a m e a p p e a r s t o b e l o n g t o t h e l e s s e r s o c i o - e c o n o m i c g r o u p s . T h e y a r e i n a l a r g e p r o p o r t i o n women o v e r t h e a g e s o f 75 who most l i k e l y r e l y on t h e i r o l d age p e n s i o n a s t h e s o l e s o u r c e o f income as many o f them, d u r i n g t h e i r w o r k i n g y e a r s p r o b a b l y r e l i e d on t h e i r h u s b a n d ' s income w h i l e r a i s i n g a f a m i l y , o r i f w o r k i n g , most l i k e l y d i d n o t c o n t r i b u t e t o an a d v a n t a g e o u s p e n s i o n p l a n , i f any a t a l l . The l o w e r s t a t u s i s a l s o i n d i c a t e d by t h e f a c t t h a t t h e y a r e more l i k e l y t o r e n t t h e i r d w e l l i n g a s o p p o s e d t o owning one and t h e r e f o r e a l a r g e p o r t i o n o f t h e i r income g o e s t o w a r d s p a y i n g t h e r e n t . T h i s s i t u a t i o n i s f u r t h e r a g g r a v a t e d by t h e f a c t t h a t many o f t h e s e women l i v e a l o n e ( p r o b a b l y many 59 a r e widowed) and t h e r e f o r e c a n n o t s h a r e t h e c o s t s o f l i v i n g and r e n t w i t h a p a r t n e r . O v e r a l l , t h e most l i k e l y v i c t i m o f l a b e l i n g w o u l d be an e l d e r l y woman o v e r t h e age o f 75 on a f i x e d income who l i v e s a l o n e i n an a p a r t m e n t b u i l d i n g . SAMPLING PROCEDURE Two t y p e s o f s a m p l e s were s e l e c t e d f o r t h e s t u d y . F i r s t , f i v e i n d i v i d u a l s o v e r t h e age o f 65 were s e l e c t e d t o f o r m a s m a l l c a s e s t u d y sample f o r t h e p u r p o s e o f g a t h e r i n g i n - d e p t h q u a l i t a t i v e d a t a on t h e i r c a s e h i s t o r y t h r o u g h p a r t i c i p a n t o b s e r v a t i o n and i n t e r v i e w i n g . T h e s e i n d i v i d u a l s were p u r p o s e l y s e l e c t e d a c c o r d i n g t o t h e s o u r c e o f t h e i r r e f e r r a l s i n an e f f o r t t o i n c l u d e i n t h i s sample t h e i n s t i t u t i o n s w h i c h most t y p i c a l l y r e f e r t h e e l d e r l y t o t h e Community M e n t a l H e a l t h Team. A s e c o n d more i n c l u s i v e s a m ple was s e l e c t e d u s i n g t h e r e f e r r a l f o r m s o f a l l p e o p l e o v e r 65 r e f e r r e d t o t h e m e n t a l h e a l t h team between J a n u a r y and December 1987. S i x t y - f i v e f o r m s were r e v i e w e d t o o b t a i n b a s i c d e s c r i p t i v e s t a t i s t i c s on d e m o g r a p h i c s , r e s i d e n c e , s o u r c e o f r e f e r r a l and r e a s o n f o r r e f e r r a l . The p u r p o s e o f t h i s sample was a l s o t o v e r i f y t h e r e p r e s e n t a t i v e n e s s o f t h e s m a l l c a s e s t u d y s a mple on t h e above m e n t i o n e d v a r i a b l e s a l t h o u g h t h i s c o m p a r i s o n i s a t b e s t t e n u o u s due t o t h e l a r g e N d i f f e r e n c e b etween t h e two s a m p l e s . F u r t h e r m o r e , t h e p u r p o s e o f t h e s m a l l s a mple was t o g a t h e r 60 e x p l o r a t o r y i n - d e p t h i n f o r m a t i o n r a t h e r t h a n t r y i n g t o c o m p i l e s t a t i s t i c a l l y m e a n i n g f u l d a t a . R e f e r r a l Forms Sample The f o l l o w i n g d e m o g r a p h i c i n f o r m a t i o n was o b t a i n e d f r o m t h e r e f e r r a l f o r m s a m p l e . A t o t a l o f 65 c h a r t s were r e v i e w e d o f p e o p l e r e f e r r e d t o t h e Community M e n t a l H e a l t h Team between J a n u a r y and December, 1987 who were 65 y e a r s o f age o f more a t t h e d a t e o f t h e i r r e f e r r a l . T h i s number r e p r e s e n t s a p p r o x i m a t e l y 72 p e r c e n t o f t h e t o t a l number o f r e f e r r a l s o f e l d e r l y p e o p l e t o t h e team f o r t h a t y e a r (N = 90 r e f e r r a l s ) . Twenty f i v e c h a r t s were u n a v a i l a b l e f o r r e v i e w a t t h e t i m e b e c a u s e t h e y were e i t h e r l o c a t e d a t a n o t h e r team s u b s e q u e n t t o t h e t r a n s f e r o f t h e c l i e n t , o r were i n a d v e r t e n t l y m i s p l a c e d o r d i s c a r d e d b y team s t a f f . Of t h e 65 c h a r t s r e v i e w e d , 31 p e r c e n t (N = 20) were m a l e w i t h t h e y o u n g e s t s u b j e c t b e i n g 65 and t h e o l d e s t , 84. The a v e r a g e age f o r t h e sample was 72 y e a r s . The m a j o r i t y o f t h e s u b j e c t s were f e m a l e s , m a k i n g up 69 p e r c e n t o f t h e sample, w i t h t h e y o u n g e s t f e m a l e s u b j e c t b e i n g 65 y e a r s o f age and t h e o l d e s t , 89, w i t h an a v e r a g e age f o r t h a t s a m p l e o f 76. The a v e r a g e s a mple age f o r b o t h s e x e s was 74. The v a s t m a j o r i t y o f i n d i v i d u a l s r e f e r r e d t o t h e team i n t h a t s a m ple r e s i d e d i n a p a r t m e n t s (N = 59 o r 90 p e r c e n t o f t h e s a m p l e ) . Two t y p e s o f a p a r t m e n t r e s i d e n c e were i d e n t i f i e d w i t h 72 p e r c e n t (N = 47) l i v i n g i n r e g u l a r n o n - s u b s i d i z e d a p a r t m e n t b u i l d i n g s , and 18 p e r c e n t (N = 12) r e s i d i n g i n l a r g e 61 g o v e r n m e n t s u b s i d i z e d s e n i o r s ' a p a r t m e n t c o m p l e x e s . The l a t t e r i s d i s t i n g u i s h e d f r o m r e g u l a r a p a r t m e n t b u i l d i n g s b e c a u s e t h e r e n t i s l e s s t h a n t h e e q u i v a l e n t a p a r t m e n t r e n t b e c a u s e i t i s s u b s i d i z e d , and t h e y o f f e r a number o f i n - h o u s e s e r v i c e s t o t h e i r r e s i d e n t s w h i c h a r e u n a v a i l a b l e t o o t h e r d w e l l e r s s u c h a s a f u l l - t i m e n u r s e a s s i g n e d t o t h e b u i l d i n g and v a r i o u s o r g a n i z e d r e c r e a t i o n a l a c t i v i t i e s s u c h a s b i n g o s and o u t i n g s . The r e m a i n d e r o f t h e s a m ple c o n s i s t e d o f one s i n g l e i n d i v i d u a l (2% ) r e s i d i n g i n a s i n g l e u n i t home and f i v e e l d e r l y (8% ) r e s i d i n g i n n u r s i n g homes. The C e n s u s t r a c t d a t a a l s o compares f a v o r a b l y w i t h t h e r e f e r r a l f o r m sample on t h e v a r i o u s p o p u l a t i o n c h a r a c t e r i s t i c s ( s e e T a b l e s I I and I I I ) . One c o u l d v e n t u r e t o s a y t h a t t h e s a m p l e t a k e n f r o m t h e r e f e r r a l f o r m s f o r 1987 i s r e l a t i v e l y r e p r e s e n t a t i v e o f t h e p o p u l a t i o n i n t h e c a t c h m e n t a r e a o f t h e Community M e n t a l H e a l t h Team i n r e g a r d s t o age, s e x , and d w e l l i n g t y p e b a s e d on i t s c o m p a r i s o n w i t h t h e 1986 C e n sus s a m p l e . A l t h o u g h t h e r e i s a one y e a r d i f f e r e n c e b e t w e e n t h e two s e t s o f d a t a , i t i s u n l i k e l y t h a t t h e C e n s u s d a t a f o r t h e e l d e r l y w o u l d c h a n g e t h a t much o v e r a one y e a r p e r i o d as t h e e l d e r l y a r e a f a i r l y s t a b l e segment o f t h e p o p u l a t i o n . C a s e S t u d y Sample I n r e g a r d s t o t h e c a s e s t u d y sample, f i v e s u b j e c t s were s e l e c t e d f r o m r e f e r r a l s made t o t h e team b e t w e e n September 1987 and May 1988. A l l f i v e s u b j e c t s were o v e r age 65 w i t h t h e y o u n g e s t b e i n g 69 and t h e o l d e s t 77. T h e r e were t h r e e 62 T a b l e I I P o p u l a t i o n C h a r a c t e r i s t i c s - R e f e r r a l Form Sample (N=65) Male Female Male & Female N 4 N i N 4 65-74 years 75 years and over 14 6 (22) (9) 26 19 (40) (29) 40 25 (62) (38) Total Population: (Both age groups) 20 (31) 45 (69) 65 (100) Dwellings Type: N i S ingle detached home 1 (2) Apartments 59 (90) Others (Nursing Home) 5 (8) To t a l 65 100 Table III Comparison of Population Ch a r a c t e r i s t i c s -Census Tract and Referral form Sample Male Census Sample Female Census Sample Male & Female Census Sample 65-74 years 75 years and over 27 13 22 9 28 32 40 29 55 45 62 38 Total Population: (Both age groups) 40 31 60 69 100 100 Dwellings Types Single detached home Apartments Others Total Census 11 72 27 100 Sample 2 90 100 64 m a l e s (60%) and two f e m a l e s (30%) i n t h e sample w h i c h i s a r e v e r s a l o f t h e m a l e / f e m a l e r a t i o o b t a i n e d f o r t h e c h a r t s a m p le ( 3 1 % mal e and 69% f e m a l e ) . The a v e r a g e age f o r b o t h 1 s e x e s was 72, w i t h t h e a g e s f o r t h e m a l e s b e i n g i n d e c r e a s i n g o r d e r , 77, 70 and 69; and f o r t h e f e m a l e s , 73 and 71. The a v e r a g e age f o r t h i s s a m ple i s t h e r e f o r e l o w e r t h a n t h e c h a r t s a m p l e f o r f e m a l e s w h i c h was 74, and t h e same f o r t h e male r e f e r r a l f o r m s a m p l e . The s m a l l c a s e s t u d y sample d i d n o t c o r r e s p o n d t o t h e r e f e r r a l f o r m s a mple i n r e g a r d s t o r e s i d e n c y . The number o f i n d i v i d u a l s f r o m N u r s i n g homes were o v e r p r e s e n t e d i n t h e c a s e s t u d y s a m p l e w i t h 4 0 p e r c e n t o f t h e i n d i v i d u a l s (N = 2 o u t o f 5) b e i n g r e f e r r e d f r o m homes a s compared t o o n l y 8 p e r c e n t f o r t h e o t h e r s a m ple (N = 5 o u t o f 65) . Two e l d e r l y l i v e d i n e i t h e r r e g u l a r o r g o v e r n m e n t s u b s i d i z e d a p a r t m e n t b u i l d i n g s w h i c h i s u n d e r p r e s e n t a t i v e o f t h a t t y p e o f l i v i n g s i t u a t i o n c o mpared t o t h e f o r m s ample (40 p e r c e n t v s . 90 p e r c e n t ) . F i n a l l y , o n l y one i n d i v i d u a l was l i v i n g i n h i s own home p r i o r t o b e i n g a d m i t t e d t o a p s y c h i a t r i c ward o f a g e n e r a l h o s p i t a l and s u b s e q u e n t r e f e r r a l t o t h e m e n t a l h e a l t h team. I t s h o u l d be n o t e d t h a t c o m p a r i s o n between t h e s a m p l e s i s a t b e s t t e n t a t i v e due t o sample s i z e d i f f e r e n c e . T h u s , i f t h e s m a l l e r s i z e c a s e s t u d y s a m p l e i s n o t n e c e s s a r i l y s t a t i s t i c a l l y r e p r e s e n t a t i v e o f t h e e l d e r l y p o p u l a t i o n r e f e r r e d t o t h e team, i t n e v e r t h e l e s s p r o v i d e s a r i c h n e s s o f i n - d e p t h i n f o r m a t i o n t h a t c o u l d n o t be a c h i e v e d i n t h e l a r g e r s a m p l e , g i v e n t h e t i m e c o n s t r a i n t s o f t h i s t h e s i s . 65 DESCRIPTION OF CASES S i n c e t h e c a s e s t u d i e s a c c o u n t f o r t h e b u l k o f my d a t a , I w i l l b r i e f l y d e s c r i b e t h e i r c a s e h i s t o r i e s t o g i v e t h e r e a d e r more f a m i l i a r i t y w i t h t h e e v e n t s , p e o p l e , a n d i n s t i t u t i o n s t h a t s h a p e d t h e s e i n d i v i d u a l s ' l i v e s . The c a s e s w i l l o n l y be i d e n t i f i e d by g e n d e r and a l e t t e r s o a s t o p r e s e r v e t h e i r a n o n y m i t y . Mr. W. T h i s s i x t y - n i n e y e a r o l d s i n g l e C a u c a s i a n man was r e f e r r e d t o t h e m e n t a l h e a l t h team by t h e manager o f a c o n s t i t u e n c y o f f i c e . The man h a d b e e n f r e q u e n t i n g t h e o f f i c e f o r a p p r o x i m a t e l y t h e l a s t y e a r o r s o f o r v a r i o u s s e r v i c e s r e g a r d i n g m a i n l y h i s f i n a n c e s and f i l l i n g o u t v a r i o u s g o v e r n m e n t f o r m s . He was t h e n d e s c r i b e d b y t h e manager o f t h e o f f i c e a s a g e n t l e , s o f t s p o k e n man who was i n v a r i a b l y w e l l d r e s s e d . However, a p p r o x i m a t e l y f o u r months p r i o r t o t h e r e f e r r a l , s h e s t a r t e d t o n o t i c e what s h e c a l l e d "a g r a d u a l d e t e r i o r a t i o n i n t h i s man's c o n d i t i o n " . He a p p e a r e d c o n f u s e d a b o u t where he l i v e d , a t t i m e s t h i n k i n g he was i n O n t a r i o , h i s b i r t h p l a c e ; o r t h a t he was w o r k i n g f o r a s c h o o l f o r m e n t a l l y d i s a b l e d c h i l d r e n , w h i c h he d i d b u t a b o u t f o r t y y e a r s ago. He s t a r t e d s h o w i n g up t o t h e o f f i c e a t l e a s t o n c e a week i n a s t a t e o f c o n f u s i o n and o f t e n e m o t i o n a l l y d i s t r e s s e d . 66 The o f f i c e manager c a l l e d the Community Mental Health Team as a l a s t resort a f t e r attempting to obtain help from other services including the P r o v i n c i a l Housing Corporation (which supervised the apartment building i n which Mr. W. resided), long term care, and the Police Department. This man was then assessed by the g e r i a t r i c s p e c i a l i s t at the team and one p s y c h i a t r i s t and they suspected he suffered from "a form of primary degenerative dementia". They referred him to a g e r i a t r i c assessment unit i n a general ho s p i t a l for assessment and the diagnosis hence obtained confirmed t h e i r suspicion. He was subsequently referred by the g e r i a t r i c s p e c i a l i s t to a nursing home. Miss D. This 73 year old single Caucasian female was referred by a s o c i a l service agency who inherited t h i s case following her arrest by the p o l i c e on charges of t h e f t under one thousand d o l l a r s . The events leading to her arrest are as follows: she was spotted by two policemen going from car to car t r y i n g to open t h e i r doors i n a parking l o t behind the p o l i c e s t a t i o n . Alerted by her suspicious behavior, one of the policemen walked toward her as she was entering a BMW of which i t s owner had inadvertently l e f t the doors unlocked. She subsequently was charged and summoned to appear i n court for sentencing. This was not Miss D.*s f i r s t offense. She was previously arrested eleven times and charged seven times for the same 67 offense between 1982 and 1988. The worker from the s o c i a l services agency who referred her started to suspect that her behavior could be attributed to "some form of dementia which pushed her to break into cars and s t e a l things". As a r e s u l t , he sought the p s y c h i a t r i c expertise of the Mental Health Team to v e r i f y h i s suspicions. Miss D. received her t r i a l a f t e r numerous attempts where she d i d not show up at scheduled court appearances. The judge suspended the charges but ordered her to attend regular meetings with her probation o f f i c e r and to receive treatment from the Mental Health Team. She agreed to the terms of her probation order but only attended the team on a few occasions and then vanished. The g e r i a t r i c s p e c i a l i s t at the team t e n t a t i v e l y established that she was s u f f e r i n g from depression and had a low self-esteem related to the loss of her parents approximately one year before her f i r s t arrest, and therefore was seeking confirmation of worthlessness by committing a n t i -s o c i a l acts such as breaking into cars and s t e a l i n g . At the time of writing t h i s report, I heard from her probation o f f i c e r that she recently has been charged again with breaking into cars. Mrs. S. Mrs. S. i s a 73 year old widowed resident of a nursing home. She i s of Polish descent and immigrated to Canada a f t e r the war, a f t e r having survived the NAZI decimation of her v i l l a g e where she l o s t family and friends to the concentration 68 camps. She was admitted to the nursing home approximately two years ago following a major depressive episode following the death of her husband where she was h o s p i t a l i z e d on the p s y c h i a t r i c ward of a general h o s p i t a l . She was referred to the Mental Health Team by the charge nurse of the nursing home because of concerns regarding her "depressed and paranoid behavior". The nurse said that Mrs. S. contracted a urinary t r a c t i n f e c t i o n about one month p r i o r to her r e f e r r a l which was successfully treated with a n t i b i o t i c s . However, she feared that her mental state had been affected because she i n s i s t e d on staying i n her room, did not p a r t i c i p a t e i n the home's a c t i v i t i e s and did not communicate with the s t a f f and at times was uncooperative to t h e i r demands. She was seen at the team by one of the s t a f f and a p s y c h i a t r i s t . Both were f a m i l i a r with her case having had her as a c l i e n t for approximately one year following her discharge from a p s y c h i a t r i c ward and her a r r i v a l at the nursing home. In t h e i r assessment they both f e l t that Mrs. S. did not evidence signs of depression or paranoid behavior but rather at t r i b u t e d her suspicious and withdrawn behavior to her natural untrusting s e l f , a personality t r a i t that stemmed from having to survive the NAZI persecution i n her native country and to her feelings of embarrassment around her i n f e c t i o n which frequently made her lose control of her bladder. They also f e l t that she appeared uncommunicative because of her shyness and her poor command of the English language. 6 9 Therefore, t h e i r decision was that Mrs. S. was not i n need of p s y c h i a t r i c treatment and did not require medication as requested by the nurse in-charge at the home. However, three weeks l a t e r a f t e r much insistence from the home's head nurse that medication would improve Mrs. S.'s mental state, and because there did not seem to be a change i n her behavior, the p s y c h i a t r i s t changed his mind and prescribed her an a n t i -depressant. Mr. L. Mr. L. i s a 77 year old Caucasian gentleman who was admitted to the p s y c h i a t r i c ward of a general h o s p i t a l because of a suicide attempt at his home following a p a r t i c u l a r l y bad argument with his wife. He was f i r s t sent to a medical ward for treatment and was l a t e r transferred to the p s y c h i a t r i c ward where he stayed for one and a h a l f months before being referred to the Mental Health Team for follow-up care upon his discharge from h o s p i t a l . Mr. L. was i l l informed about what the mental health team was a l l about and was somewhat annoyed that • he would also have to see a p s y c h i a t r i s t when out of h o s p i t a l for what he c a l l e d "a moment of temporary insanity". He denied having further intentions to harm himself although he also added that death would be a welcomed r e l i e f . The root of h i s problems he claimed was p a r t l y the marital discord between him and h i s wife, which was resolved through separation, but most importantly the i l l state of his health. He nevertheless agreed to attend the Team. Mr. L. was 70 assessed as su f f e r i n g from depression by the p s y c h i a t r i s t at the team and was put on a t r i a l of anti-depressant medication. Mr. M Mr. M. i s a 70 year old r e t i r e d engineer who contracted Huntington's disease one year a f t e r retirement. His condition gradually deteriorated to the point where he was unable to care for himself independently. He was transferred to a nursing home where he was res i d i n g at the time of his r e f e r r a l to the Mental Health Team. Mr. M. was referred to the mental health team because the di r e c t o r of the home found him to be aggressive with a propensity to h i t s t a f f i n an unpredictable manner, e s p e c i a l l y nursing s t a f f who helped him with h i s meals. The di r e c t o r f e l t that the man should be c e r t i f i e d and removed from the home into a p s y c h i a t r i c f a c i l i t y . The team did assess Mr. M. on two occasions but found him to be not c e r t i f i a b l e due to his r a t i o n a l thinking and non-threatening behavior. His primary therapist at the Team conjectured that h i s s t r i k i n g out attempts were involuntary and caused by chorea-form movements related to h i s d i s a b i l i t y which l e f t him with poor coordination and control of his muscles. The fact that he " h i t " at s t a f f was probably not a premeditated act but an accident a r i s i n g from the fac t that a s t a f f member would be standing near him, e.g., feeding him, as his arms would be moving i n an uncontrollable fashion. 71 The d i r e c t o r of the home was quite upset that the Team was not w i l l i n g to c e r t i f y the man and as a r e s u l t requested hi s physician to increase the dosage of the t r a n q u i l i z e r he was on to control h is "aggressive" behavior. Mr. M. was subsequently transferred to another nursing home. 72 CHAPTER 4 IDENTIFYING DEVIANCE IN THE COMMUNITY: THE ROLE OF REFERRING AGENTS If deviance i s a s o c i a l l y a ttributed condition then the status of deviant i s an ascribed one (Conrad, 1980). Deviance i n the e l d e r l y referred to the Mental Health Team i s defined as such by key r e f e r r i n g agents i n the community who evaluate, define, and ascribe such status i n the people they r e f e r . Hence, r e f e r r a l s to the team are a function of the process of a t t r i b u t i n g deviance by community agents. The purpose of t h i s section i s describe the r e f e r r i n g agents of deviance and the reasons behind t h e i r r e f e r r a l s . THE REFERRING AGENTS: WHO ARE THEY AND WHY DO THEY  REFER TO THE COMMUNITY MENTAL HEALTH TEAM? Mental i l l n e s s i n the e l d e r l y i s r a r e l y f i r s t detected by mental health services. Rather i t i s brought to t h e i r attention by a va r i e t y of sources including friends or r e l a t i v e s , but mainly by the other services which cater to the needs of that population, e.g., nursing homes, police force. In the r e f e r r a l form sample, 68 percent (N = 44) of the primary i d e n t i f i e r s of i l l n e s s who referred to the team were professionals although out of that number, only 14 percent (N = 9) were mental health professionals. The remaining 2 6 73 percent (N = 7) were non-professionals and only 6 percent (N =4) of the sample ac t u a l l y referred themselves for services (see Table IV) . A l l professionals referred to the Mental Health Team as part of t h e i r professional duties within the service agency they worked for. A l l service agencies involved provide eit h e r d i r e c t or i n d i r e c t services to the e l d e r l y . An example of a d i r e c t service would be that of a nurse i n a nursing home where as an i n d i r e c t service would be that of a p o l i c e o f f i c e r who helped an e l d e r l y person i n the function of his/her duty but whose r o l e i s not exc l u s i v e l y that of caring for the e l d e r l y . Out of 57 professionals and non-professionals who referred to the Team, 42 percent (N = 24) provided a d i r e c t service to the e l d e r l y and 58 percent (N = 33) provided an i n d i r e c t service to the aged. F i n a l l y , only 14 percent (N = 9) of i n d i v i d u a l s r e f e r r i n g were working as professionals i n some form of mental health service. These percentages indicate that professionals who have more frequent contact with the e l d e r l y or work i n a mental health s e t t i n g do not necessarily r e f e r the e l d e r l y more frequently for community p s y c h i a t r i c care than people who have le s s frequent contact with them or professionals who do not work within the mental health system. However, i t i s evident that professionals tend to r e f e r s i g n i f i c a n t l y more to the team than non-professionals do (68% versus 26%) , excluding s e l f - r e f e r r a l s ) . T a b l e I V S o u r c e o f R e f e r r a l b y R e f e r i n g A g e n t a n d S e r v i c e A g e n c y F r o m R e v i e w o f 1 9 8 7 R e f e r r a l F o r m s S a m p l e (N = 65 ) Referring Agent 1- Professionals i n other services than mental health services, 2- Apartment Managers Service Agency Long term care, nursing home B.C. Housing, private apartment bu i l d i n g . 3-General P r a c t i t i o n e r Self-employed 4- Professionals-Mental Health Services 5- Relatives/friends 6- S e l f 7- P o l i c e O f f i c e r s Hospital p s y c h i a t r i c ward Police Dept. Total N 22 11 10 9 4 4 3 65 % 32 17 15 14 6 6 5 100 75 The higher propensity of professionals to re f e r to the team can be explained by t h e i r greater awareness of that service being available to the mentally i l l . In the sample of case studies, a l l f i v e r e f e r r i n g agents had made at le a s t one previous r e f e r r a l to the Team and were quite aware of the nature of i t s service. In one case, one r e f e r r i n g agent attempted to obtain help from three other service agencies for a man who frequented her constituency o f f i c e i n a confused state before f i n a l l y contacting the Mental Health Team as a l a s t resort. She was aware that a g e r i a t r i c s p e c i a l i s t was operating on the Team and even knew him by hi s f i r s t name from previous dealings with him on a s i m i l a r case. Yet, that r e f e r r i n g agent had only l i m i t e d knowledge of mental i l l n e s s and described the e l d e r l y man's problems as "there i s something wrong with him". This case i s somewhat t y p i c a l of other r e f e r r i n g agents i n the case study sample as none of the other agents interviewed had in-depth knowledge of mental i l l n e s s processes despite the occasional attempt to diagnose the referred person's problem. These amateur diagnoses were inv a r i a b l y disconfirmed by the team's p s y c h i a t r i s t s . For example, a nurse i n a nursing home referred an e l d e r l y female resident for "paranoid behavior". She was assessed by one of the team's p s y c h i a t r i s t s and was found instead to be depressed. In another case, an e l d e r l y man was referred because he had "unpredictable physical outbursts" and because he was "violent and depressed". On the insistence 76 of the nursing home d i r e c t o r who had referred t h i s man, the Mental Health Team assessed him on three d i f f e r e n t occasions with three d i f f e r e n t p s y c h i a t r i s t s who a l l found him to be " l o g i c a l and coherent", not "depressed and demented", and "quite approachable and pleasant i n h i s manners". In both of these cases however, the r e f e r r i n g agents had previously made numerous r e f e r r a l s to the Team and were f a m i l i a r with the g e r i a t r i c s p e c i a l i s t ' s r o l e on that team. In fact, approximately two years p r i o r to the above mentioned r e f e r r a l s , both nursing homes had been approached by that s p e c i a l i s t i n an e f f o r t to promote h i s sp e c i a l i z e d services to them. This move had occured for the purpose of esta b l i s h i n g what the g e r i a t r i c i a n c a l l e d "an early warning system" of in d i v i d u a l s i n the community who could detect early signs and symptoms of mental i l l n e s s i n the elde r l y , and subsequently r e f e r them to the Mental Health Team for assessment and treatment. The people targeted i n the community for t h i s system included a wide range of lay i n d i v i d u a l s as well as professionals who were regularly i n contact with the e l d e r l y . They were caretakers of apartments or hotels where a large number of el d e r l y l i v e d , nurses and health care workers i n nursing homes, members of senior c i t i z e n organizations, long term care assessors, and administrators working for the P r o v i n c i a l Housing Corporation which manages two large subsidized apartment buildings for seniors. Furthermore, the g e r i a t r i c s p e c i a l i s t also appeared on 77 community t e l e v i s i o n on a program s p e c i f i c a l l y geared towards the aged. The ultimate r e s u l t of t h i s educational process was to generate a network of amateur diagnosticians who were se n s i t i z e d to any behavior i n the e l d e r l y which deviated from the accepted norm for that population. I t became e s s e n t i a l l y a large net which dragged i n , along with some cases pathology requiring professional help, a large array of deviance which even psychiatry has yet to categorize as i l l n e s s . An example of t h i s 'early warning system' operating i n that way i s the case of an e l d e r l y woman l i v i n g i n a shoddy hotel i n a not so sanitary section of downtown. The manager of that hotel made a r e f e r r a l to the Mental Health Team because he f e l t t h i s woman was acting out, being aggressive, and causing damage to property. He suspected t h i s woman to be s u f f e r i n g from a serious mental problem and that she f e l t should be sent to a mental h o s p i t a l . The g e r i a t r i c i a n and myself went to investigate the s i t u a t i o n . Upon our a r r i v a l at the hotel, we met with the c l i e n t , a woman i n her 70's who was i n the process of cooking some lunch for herself. She welcomed us, offered us some tea, and spoke to us i n a most pleasant and r a t i o n a l manner. She admitted to having been v e r b a l l y abusive towards the manager of the hotel because she f e l t he was charging her excessive rent. The whole thing resulted i n a heated argument between the two of them and out of 78 f r u s t r a t i o n , she kicked a hole i n the wall of her room. Not sur p r i s i n g l y , the g e r i a t r i c i a n concluded that t h i s woman was i n no way mentally i l l or i n need of h o s p i t a l i z a t i o n . A f t e r our assessment, we met with the hotel manager, a middle-aged o r i e n t a l man, and the g e r i a t r i c i a n informed him of h i s v e r d i c t . The manager stared at us i n d i s b e l i e f and i n h i s broken English, said, "Her, go to hosp i t a l . crazy", while tapping the side of h i s head with h i s index finger. Alas to his disappointment, we l e f t without sending the e l d e r l y woman to an insane asylum. Unfortunately, as we learned the next day, she was summarily evicted from the hotel by the manager a f t e r what we assumed must have been another heated argument since he also h i t her over the head with a f r y i n g pan i n the process of doing so. This case also i l l u s t r a t e s how the e l d e r l y gain access to the Mental Health Team mostly against t h e i r w i l l . In fact, they are referred to the team i n a proportion of 94 percent by a t h i r d party who usually occupies a po s i t i o n of authority, e.g., general p r a c t i t i o n e r , apartment or hotel manager. Only 6 percent of those t h i r d party r e f e r r a l s are made by friends or r e l a t i v e s and most r e f e r r a l s are done without the awareness or consent of the referred e l d e r l y . Therefore, one can conclude that they have l i t t l e say i n determining whether or not they receive mental health services. I t i s true that the service i s voluntary i n nature and that when approached by a mental health worker, an e l d e r l y person can always refuse the service. However, 79 the e l d e r l y are also vulnerable i n regards to making informed decisions regarding accepting or refusing services. Their understanding of mental health services i s d i f f e r e n t from that of younger cohorts and they may be a f r a i d that refusing to see a professional may mean that they w i l l be f o r c e f u l l y carted away to the asylum (Lasoski, 1986). This problem can be further aggravated by how such service i s introduced. In a number of instances for example, the g e r i a t r i c i a n from the Mental Health Team introduced himself as being from the "Health Department' i n order to access the e l d e r l y who were reluctant to see a mental health professional. THE NATURE OF THE DEVIANCE REFERRED BY AGENTS Regardless of the s p e c i f i c content of behavior, the e s s e n t i a l nature of deviance i d e n t i f i e d by the r e f e r r i n g agents l i e s i n the departure of the e l d e r l y from cert a i n norms which are accepted and at times enforced by the s p e c i f i c groups to which they belong. Some of the norms broken tended to be more universal i n t h e i r scope, e.g., generally recognized as such by society, whereas others tended to be s p e c i f i c to the i n s t i t u t i o n s providing services to the e l d e r l y , such as refusing to p a r t i c i p a t e i n a nursing home a c t i v i t y program. Key norm breaking behaviors were inv a r i a b l y given to the intake worker upon the r e f e r r a l and l i s t e d on the r e f e r r a l form. 80 Further information on these behaviors was given by the agent upon the v i s i t of the team s t a f f responding to the r e f e r r a l . Team s t a f f , usually one therapist and a p s y c h i a t r i s t , spent much time discussing the nature of such behaviors with the agents i n an e f f o r t to assess the el d e r l y ' s l e v e l of pathology. Quite often time spent with the agents exceeded time spent with the referred e l d e r l y . Eight key norm breaking behaviors were i d e n t i f i e d as the most common ones reported by r e f e r r i n g agents from the case study sample and the r e f e r r a l form sample. They w i l l be described below Hycriene Neglect Personal hygiene i s a norm which i s very much emphasized i n society judging by the amount of p u b l i c i t y on beauty products destined to eradicate any suspicious odors coming from any parts of the anatomy one cares to expose to other fellow human beings. Anyone smelling and looking d i r t y tends to stand out i n t h i s kind of environment, e s p e c i a l l y i f they happen to be older than most. The i n a b i l i t y of the e l d e r l y to care for t h e i r hygiene was one of the most common reasons c i t e d by r e f e r r i n g agents as indicators of mental i l l n e s s . In one of the case studies, i t was the primary reason and i n two others, poor hygiene was mentioned as a secondary reason supporting the agents' primary a t t r i b u t i o n of i l l n e s s . As for the sample of r e f e r r a l forms, hygiene neglect was the second most 81 mentioned reason for a t t r i b u t i n g mental i l l n e s s next to depression (14 percent of a l l r e f e r r a l s ) . The perceived severity of hygiene neglect by the r e f e r r i n g agent appeared to vary according to the context i n which t h i s norm breaking behavior was i d e n t i f i e d . The factors influencing t h e i r evaluation of severity seemed to be a function of both occupation and loc a t i o n of the labeler of deviance. Professional caretakers such as a nurse or an o f f i c e manager tended to notice neglect more r e a d i l y than non-professionals and peers because i t stands out more r e a d i l y i n environments where cleanliness i s more of a norm, e.g., a nursing home, o f f i c e . As comparative case examples of the r o l e of context on the d e f i n i t i o n of deviance, we w i l l consider the cases of Mrs. S. and Mr. W. Mrs. S. i s an e l d e r l y woman res i d i n g i n a nursing home run by a Catholic order of nuns. At the time of her r e f e r r a l to the mental health team, she suffered from an urinary t r a c t i n f e c t i o n which made her occasionally incontinent of urine i n most inopportune places. On one occasion, t h i s woman accidently voided h e r s e l f i n the chapel. The incident d i d not go unnoticed by the nursing s t a f f , a l l of whom were nuns. I t was charted i n her f i l e by the following sentence underlined i n red: "Mrs. S. voided  i n the chapel!" Mrs. S. had desanctified the most sacred of places within that home. Later, Mrs. S. took to her room not daring to venture outside into the building, most probably for fear of voiding again. This behavior was 82 referred to as "paranoid" by the same nursing s t a f f who were offended at her "unhygienic" behavior i n the chapel. Other unhygienic behavior reported i n the case included her reluctance to wash her face and comb her hair i n the morning. Yet, when I interviewed t h i s woman i n her room I c e r t a i n l y could not detect e i t h e r v i s u a l l y or o l f a c t o r a l l y any signs of hygiene neglect. Now compare that case with the case of Mr. W. who l i v e d independently i n the community before h i s r e f e r r a l to the team. I t was subsequently found that he suffered from major brain damage due to primary dementia. This condition had been occurring approximately eight months p r i o r to his r e f e r r a l . Appearance wise, Mr. W. showed very obvious signs of neglect. His clothes were d i r t y with stains and smelled. His fingers had large nicotine stains on them, hi s thinning unwashed h a i r was lumped together by grease, and he had not been shaving for a few days. Interestingly enough, Mr. W. l i v e d i n a large apartment complex for senior c i t i z e n s and interacted on a d a i l y basis with the other residents i n the b u i l d i n g and with the caretaker. I t appears that none of these people thought h i s appearance and lack of hygiene were unusual enough to warrant reporting him to the mental health team or for that matter of fact to any authority, e.g., p o l i c e . Yet, the caretaker knew of the existence of the team from previous consultations with the g e r i a t r i c s p e c i a l i s t . In fact, Mr. W. was referred to the team by the manager of a nearby constituency o f f i c e who had noticed that 83 Mr. W.'s appearance had been deteriorating over the few months of her contact with him. This case comparison i l l u s t r a t e s that the d e f i n i t i o n of deviance can be influenced by factors external to the inherent behavior of the i n d i v i d u a l . In t h i s case, the lack of tolerance of the r e f e r r i n g agents for the indiv i d u a l s hygiene neglect contributed to a speedier r e f e r r a l to the mental health team. These people presumably assumed that anyone not keeping themselves clean i s incapable of doing so and therefore must be s u f f e r i n g from some form of mental impairment. I t should be noted however, that i n some cases, hygiene neglect had been i d e n t i f i e d as deviant behavior along with other behaviors. Therefore i n such cases, i t i s the combination of deviant behaviors as opposed to a single behavior that led labelers to ascribe mental i l l n e s s i n a given i n d i v i d u a l . Possibly, a lack of hygiene although i n s u f f i c i e n t i n i t s e l f to motivate an agent to refer, nevertheless, a t t r a c t s his or her attention to other behaviors more symptomatic of mental i l l n e s s . D isorientation The proper functioning of our society depends on each i n d i v i d u a l 1 s capacity to remain oriented to h i s or her ascribed i d e n t i t y . I f for whatever reason, one day everyone was to forget where they l i v e d or what t h e i r name was, and at that, lose a l l t h e i r i d e n t i t y cards, then most l i k e l y 84 modern i n d u s t r i a l i z e d society as we know i t would be irrevocably altered. One i s given a s p e c i f i c i d e n t i t y , a f i r s t and l a s t name, to which i s attached a series of information es s e n t i a l for everyday s u r v i v a l : birthdate, s o c i a l insurance number, medical number, and so on. I t i s impossible to open a bank account or cash a cheque without proper i d e n t i f i c a t i o n , or to t e l l someone that you are who you claim you are unless you can prove i t with the r i g h t papers. F i n a l l y , c i t i e s have become mazes of streets and shelters each with a s p e c i f i c address i n the form of names and/or numbers. Finding an address today can require both the i n s t i n c t of an Indian hunter and the memory bank of a modern super computer. Our society also demands previously unheard of timing from i t s members to ensure i t s smooth running. People must a r r i v e and leave work at given times, they must keep appointments and the transportation they take has to come and go with pr e c i s i o n . Overall then, being oriented to time, date, and place, and to one's formal i d e n t i t y has become an e s s e n t i a l norm i n our society. I t i s easy for the e l d e r l y to deviate from t h i s norm as they tend to remember things i n the long term range (the "old days") and forget the "here and now1 d e t a i l s - today's date, the number of t h e i r apartment, etc. This tendency contravenes the norm established by the younger segment of society which the e l d e r l y come i n contact with through various services. Often to access such services, 85 the e l d e r l y must conform to that norm by being aware of dates, time, address, and various i d e n t i t y numbers. Their i n a b i l i t y to do so makes them vulnerable to being labeled deviants by service providers. In the r e f e r r a l form sample, r e f e r r a l s for reasons of d i s o r i e n t a t i o n accounted for 6 percent (N = 4) of a l l r e f e r r a l s to the team. Comments on the forms included the following: "wanders and gets l o s t - fear for safety"; "disoriented to time, place, and people"; "confused"; "wanders i n hallways, daughter wants him i n a nursing home." In the case study sample, d i s o r i e n t a t i o n was mentioned i n only one case out of f i v e , that of Mr. W. I t was given as the primary reason for r e f e r r a l : "On November , 198_, ' s o f f i c e referred t h i s 69 year old gentleman who, as a regular c a l l e r to t h e i r o f f i c e , had been exh i b i t i n g what they f e l t was a det e r i o r a t i o n of hi s mental condition over the past several months. S p e c i f i c a l l y they f e l t that he was confused as to the day, where he l i v e d , and where hi s money was". Disorientation i s also a form of deviance within i n s t i t u t i o n a l settings such as i n nursing homes for example. Individuals who tend to walk away from a home, and can not remember how to get back can pose serious management problems for the s t a f f who must then attempt to relocate t h e i r missing resident. Disorientation therefore becomes deviance which needs to be controlled to ensure the smooth running of an i n s t i t u t i o n . This control can take many forms: locked doors, tying up residents to t h e i r chairs, or confining them to t h e i r room, or t r a n q u i l i z e r s . One 86 i n t e r e s t i n g form of control I observed was the case of t h i s e l d e r l y gentleman i n a nursing home where the s t a f f figured that i f he was to wander o f f from the home, people out i n streets would most l i k e l y bring him back. To make sure of that, they sewed a large patch of f a b r i c on the back of his s h i r t . On i t was written: "I am l o s t - please c a l l 272-513_" which was the home's number. S o c i a l control indeed takes many forms. Dementia Of a l l the q u a l i f i c a t i o n s used to describe deviance i n the e l d e r l y , dementia i s probably the most commonly used one. The stereotype that old age equates s e n i l i t y i s prevalent i n our society. Old age i s associated with a multitude of problems which invar i a b l y r e l a t e to some brain malfunction. I f older people can't remember something, they're demented; i f they can't figure out the r i g h t change for the bus or are not moving f a s t enough i n a l i n e up, they are also demented. S e n i l i t y i s even part of the younger generation's popular language. How many times do we say "I must be getting o l d " i f we cannot remember something. In the r e f e r r a l form sample, the term demented was not always used d i r e c t l y . I t was i n d i r e c t l y referred to i n 2 0 percent of the cases (N = 13) where the r e f e r r i n g agent explained the behavior of the e l d e r l y person with some form of brain disorder. The following comments were noted: "something i s wrong with her mind"; "he may be paranoid or 87 demented"; "public health nurse received c a l l s from apartment manager st a t i n g possible mental deterioration i n t h i s e l d e r l y woman"• In the case study sample, dementia was c i t e d as the primary reason for r e f e r r i n g Miss D. to the team. This woman who had been referred to the team a number of times previously had the peculiar habit of entering parked cars and s h u f f l i n g through t h e i r glove compartments. This behavior had brought her before the courts . on several occasions. Despite numerous arrests and warnings however, she kept breaking into cars. Her probation o f f i c e r made a r e f e r r a l to the team because she f e l t that the only p l a u s i b l e explanation for Miss D.'s behavior was some form of brain impairment. She r a t i o n a l i z e d her explanation by sta t i n g that t h i s woman's behavior was a recent one i n occurrence, and that she was receiving a steady pension and therefore did not need to st e a l money for her subsistence. There was also the fact that t h i s woman was h i t over the head when playing baseball as a c h i l d . I nterestingly enough, the g e r i a t r i c i a n ' s assessment of t h i s woman read: "I could detect no evidence of a dementing process nor delirium. Further there was no disturbance i n form or content of thought or perception, nor was there gross disturbance i n vegetative signs". In regards to her deviant behavior however, he diplo m a t i c a l l y remarked that "There i s chronic impairment i n her judgement and insight with respect to her constantly entering into parked cars". 88 This case also serves to i l l u s t r a t e the mechanism by which deviance i s created. S o c i a l groups create deviance by making the rules whose i n f r a c t i o n constitutes deviance. In t h i s case, the i n f r a c t i o n was a criminal one and therefore deviance was ascribed by professionals within the le g a l system. Unfortunately, repeated i n f r a c t i o n s of the rules by Miss D. put the le g a l system i n a bind: should they further enforce the rules and attempt to control t h i s e l d e r l y woman of 73 by putting her i n prison? Instead, an alt e r n a t i v e explanation was sought for her behavior i n an attempt to redefine her deviance. Mental i l l n e s s i n the form of dementia seemed to be a l o g i c a l a l t e r n a t i v e - she was el d e r l y a f t e r a l l . Such explanations then s h i f t e d the r e s p o n s i b i l i t y of rule enforcement from the le g a l system onto the mental health system, to the r e l i e f of many i n the j u d i c i a l system, who would have had the imprisonment of an old woman on t h e i r conscience. Violence In someways, society has come to t o l e r a t e a certa i n amount of violence within i t s population i n the form of various crimes ranging from assaults to murders. This form of violence i s concentrated mainly amongst the younger population and i s higher for the 18-24 age group than for any other group (Diniz et a l . , 1975). Older people are not usually associated with violence and the crime scene. The over 65 are more often than not victims of violence rather 89 than the i n s t i g a t o r s . Not su r p r i s i n g l y , none of the elde r l y i n the r e f e r r a l form sample were referred for reasons of violence towards others. Some r e f e r r a l s involved various acting out behaviors such as banging on the walls or verbal abusiveness but no physical a l t e r c a t i o n s or violence were mentioned. However, i n the case study sample, 2 out of 5 people had violence as a main concern. In the case of Mr. M. violence towards s t a f f was c i t e d as the primary reason for r e f e r r a l . The r e f e r r a l form c i t e d t h i s man as "a behavioral problem . . . at times angry with unpredictable physical outbursts". The manager of hi s nursing home was also quoted as saying that t h i s man had a propensity to h i t s t a f f and was a l l i n a l l "a dangerous man". I t should be noted that Mr. M. suffered from Huntington's disease and was wheelchair bound most of the time. Yet a f t e r assessing t h i s man on three d i f f e r e n t occasions, each time using a d i f f e r e n t p s y c h i a t r i s t , the team g e r i a t r i c i a n concluded that t h i s man was not demented, not s u f f e r i n g from any psychopathology, that he was most pleasant and cooperative, and that he was d e f i n i t e l y not aggressive. The g e r i a t r i c i a n recognized that at times t h i s man may appear to h i t others but attr i b u t e d t h i s tendency to his i l l n e s s which produced "gross abnormal choreA-form movement which could r e s u l t i n h i s arms swerving about without h i s cont r o l " . Further inves t i g a t i o n from my part seemed to confirm t h i s theory, as one of the nurses who 90 witnessed one of' these "assaults" could not say with any ce r t a i n t y whether Mr. M. had intended to h i t the s t a f f . I f anything, i t looked l i k e Mr. M. did not have control over what he was doing. In the second case, that of Mr. W., violence became a serious concern for the nurse who interviewed him to determine whether or not he was a suitable candidate for admission to the g e r i a t r i c day h o s p i t a l she represented. The interview took place i n the conference room of the apartment bu i l d i n g he resided i n and throughout the whole process, Mr. W. was most compliant i n answering a l l the questions put to him. He attempted to answer them to the best of h i s a b i l i t y despite his confused state, sometimes making what could be c a l l e d "smart ass" comments to cover hi s d i s a b i l i t y as i l l u s t r a t e d here: Nurse - (serious) When did you r e t i r e , Mr. W.? Mr. W. - (laughter) Retire? I've worked a l l my l i f e . Nurse - (somewhat annoyed looking) Well, when was the l a s t time you worked? Mr. W. - I don't know . . . Nurse - (somewhat s a r c a s t i c a l l y ) Do you ever have problems with your memory, Mr. W? Mr. W. - (somewhat annoyed looking) Yeah sometimes. But I've always been l i k e that. This s t y l e of interviewing went on for about f i v e minutes and then the nurse abruptly ended her assessment. She had concluded that t h i s man was unsuitable for her day h o s p i t a l because she f e l t he was "agitated and a r i s k to the f r a i l e l d e r l y woman already on the ward". She added that she vaguely remembered t h i s man as a ps y c h i a t r i c patient from before although she wasn't quite sure, and that the hos p i t a l did not o f f e r services to mental patients because they presented a r i s k to other e l d e r l y patients. She also added that t h i s man was probably s u f f e r i n g from a brain tumor and therefore there was nothing they could do about i t . Hence, with a f i v e minute assessment, t h i s nurse had determined that t h i s e l d e r l y man who had complied to a l l her questioning and had no hi s t o r y of aggressiveness i n his previous dealings with the Team, was i n fac t a brain tumor mental patient with the pot e n t i a l to assault f r a i l e l d e r l y women. Both of these case studies exemplify how violence as a form of deviance gets attributed to the e l d e r l y to prevent them from entering an i n s t i t u t i o n as i n the case of Mr. W., or to remove them from one, as i n the case of Mr. M. Why were these two el d e r l y men perceived as aggressive individuals? A number of factors can be i d e n t i f i e d here. One i s possibly gender. Both men were assessed by professional females who may be more r e a d i l y i n t e r p r e t i n g aggressiveness i n t h e i r male patients' behavior than t h e i r male counterparts. Another factor relates more to the i n s t i t u t i o n a l context i n which both e l d e r l y patients were assessed. Whether i t be a nursing home as i n the case of Mr. M, or a h o s p i t a l ward as i n the case of Mr. W., each s e t t i n g sets c e r t a i n norms to insure the smooth functioning of the i n s t i t u t i o n and give i t some p r e d i c t a b i l i t y . This c h a r a c t e r i s t i c allows for the creation of a highly e f f i c i e n t environment i n which to provide maximum care to patients with minimum output of s t a f f time. Deviation from these norms by a patient disturbs an i n s t i t u t i o n ' s routine and jeopardizes i t s e f f i c i e n t functioning. Violence i s such deviation. Aggressive patients require more s t a f f to handle, and may injure either s t a f f or other residents i n the process. They also undermine s t a f f morale because of t h e i r physical and verbal abuse and disturb other residents. Patient aggressiveness i s to an i n s t i t u t i o n an expensive and disruptive form of deviance. Hence, i n s t i t u t i o n s are extremely cautious i n dealing with eit h e r overtly aggressive patients, e.g., Mr. M. , or p o t e n t i a l l y aggressive patients, e.g., Mr. W. The most expeditious way of dealing with such disruption i s to either t r a n s f e r them to another i n s t i t u t i o n or simply to prevent them from entering the i n s t i t u t i o n i n the f i r s t place. F a i l i n g t h i s , the i n s t i t u t i o n may seek other means of c o n t r o l . In the case of Mr. M. , he was eventually sedated with massive doses of t r a n q u i l i z e r s . 93 As for Mr. W., lucky for him, he was eventually admitted to the day hospital despite h i s poor performance on the assessment. The admitting nurse who had interviewed him grudgingly phoned back the team to say that they would "bring him i n , do a'physical, clean him up, and ship him back home". In the end however, the nursing and medical s t a f f found him so pleasant, and h i s case to be so in t e r e s t i n g from a c l i n i c a l point of view, that they kept him f o r a f u l l four week assessment, and the medical resident even used him as a case study for one of h i s presentations! Depression By far the most common reason for r e f e r r i n g an el d e r l y person to the mental health team was the perceived presence of depression. In 22 percent of the cases (N = 14) i n the r e f e r r i n g form sample, agents mentioned concerns with an el d e r l y person's mood s t a b i l i t y as the primary reason for r e f e r r a l . In v i r t u a l l y a l l the cases, the word "depressed" was used to describe the referred e l d e r l y . Phrases such as " f e e l i n g depressed" or "seems depressed" were most commonly used. The two other most frequent terms used i n conjunction with the term "depressed" were "suicide" or " s u i c i d a l " (29 percent; N = 4) and " i s o l a t e d " (14 percent; N = 2). These findings seem to correlate with various epidemiological studies, which report that depression i s the most common disorder i n up to 2 0 percent of a l l persons 94 above 65 years of age (Fry, 1986) . This age group also accounts for 25 to 30 percent of a l l known suicides (Blazer, 1982) . Depression and related suicides i n the e l d e r l y can be linked to t h e i r low socio-economic status which negatively impact both t h e i r physical and mental well-being. The e l d e r l y are more vulnerable to i l l n e s s because of t h e i r d e c l i n i n g health, which can be linked i n part to the unsanitary and dangerous work environments with which most of them were faced p r i o r to r e t i r i n g (Olson, 1982). Many of the work related i l l n e s s e s manifest themselves as what has been labeled chronic degenerative diseases of old age by the medical profession. Retirement also has an impact on the e l d e r l y ' s health. The loss of employment means a d r a s t i c reduction of income and consequently a lower s o c i a l c lass membership i f old age pension i s a l l they are l e f t with. Studies have shown consistently that lower class status predicts shorter l i f e expectancy, and higher death and morbidity rates from a l l diseases ( i b i d ) . I t also can r e s u l t i n l e s s e r opportunity for adequate lodging and food, l e i s u r e opportunities and contribute to more s t r e s s f u l l i v i n g conditions. Such conditions i n turn have an impact on the e l d e r l y ' s emotional well being. Gurland et a l (1983) report strong and consistent r e l a t i o n s h i p s between depression and physical i l l n e s s . Eastwood (1980) s i m i l a r l y correlates suicide rates with depressive disorders. Therefore, what has been 95 construed as a personal problem of psychopathology i n the aged can be reframed as a s o c i a l class problem r e s u l t i n g from the e x p l o i t i v e conditions e x i s t i n g i n a c a p i t a l i s t society which create d e b i l i t a t i n g work conditions and unequal d i s t r i b u t i o n of wealth. As Olson (1982) puts i t , the problem of health i n the e l d e r l y i s "rooted i n the larger issues of s o c i a l r e l a t i o n s of production, s t r u c t u r a l i n e q u a l i t i e s and class p r i v i l e g e , and dominance of p r o f i t s over human beings" (p. 225). Viewing the problem of depression (and possibly that of other p s y c h i a t r i c disorders) i n the e l d e r l y as i n d i v i d u a l psychopathology only serve to mask the r e a l issue of s o c i a l inequality and perpetuate the acceptance of the status quo of an e x p l o i t i v e economic system. The process of 'blaming the v i c t i m 1 for h i s or her problems i s well i l l u s t r a t e d by the case of Mr. L. who was referred to the Mental Health Team for follow-up care following h i s discharge from the p s y c h i a t r i c ward of a general h o s p i t a l . Mr. L's admission was prompted by a suicide attempt i n which he ingested large quantities of anti-freeze. His gesture was deliberate and he performed i t at his home having f u l l possession of h i s f a c u l t i e s . A f t e r drinking the poisonous f l u i d , he went to h i s bedroom and lay on his bed awaiting h i s death. However, h i s wife walked i n the bedroom and r e a l i z i n g something was wrong phoned the ambulance. Mr. 96 L. was rushed to emergency, hi s stomach pumped and subsequently, he was transferred to the p s y c h i a t r i c ward. When questioned about hi s motives, Mr. L. described his gesture as "a moment of temporary insanity" prompted by the b e l i e f that he had become an "useless i n d i v i d u a l " . He often referred to himself as "half the man I used to be" because of a s e r i e s of i l l n e s s e s on which medical technology had l i t t l e impact: chronic lung obstruction, a r t h r i t i s , chronic heart condition, on-going feelings of "giddiness" which prevented him from walking more than two or three blocks at a time, and memory loss . Upon retirement, he also had l o s t hi s main l i f e i n t e r e s t , and f e l t very much i s o l a t e d and bored e s p e c i a l l y since he did not get along with h i s wife. He also had come to be envious of her because she s t i l l worked part time and her health was such that she remained quite active and could drive h e r s e l f to her various appointments while he remained by himself at home. Mr. L. imputed h i s depression and suicide attempt to h i s i s o l a t i o n , lack of r o l e , arid poor health. The mental health system dealt with Mr. L. 's condition by i s o l a t i n g him for a period of one and a h a l f months on a p s y c h i a t r i c ward. Mr. L. described h i s treatment as "a farce" and r e c a l l e d how patients received minimal attention and support from s t a f f , and had l i t t l e say i n determining the course of t h e i r h o s p i t a l i z a t i o n . He described how most of h i s demands, whether i t was permission to v i s i t with his wife over the weekend, or getting an extra dose of sleeping medication were met by the same r i t u a l i s t i c answer: " I ' l l have to check with your doctor". Mr. L. also described how patients adapted to t h i s r i g i d environment by learning to say and do the r i g h t things. For example, during mandatory community meetings, patients were asked by nursing s t a f f to say what they would do to help themselves while i n the h o s p i t a l . Because most patients, including himself, resented the impersonal and mandatory nature of these meetings, they learned to give the answer expected by the s t a f f . I t consisted of three parts: " I ' l l go f o r a walk" (physical a c t i v i t y ) ; " I ' l l read a book" ( i n t e l l e c t u a l a c t i v i t y ) ; and " I ' l l t a l k to my nurse" (treatment). Such answers seemed to please the s t a f f as i t implied that patients remained active on the ward while seeking treatment. The r e a l i t y of i t , however, according to Mr. L. was that nursing s t a f f were so involved i n charting, dispensing medications, and t a l k i n g to the doctors that they r a r e l y had time to spend with the patients outside of group time. In the h o s p i t a l records reviewed for t h i s case, there were also no accounts of any e f f o r t s to address the issues that lead Mr. L. to despair. Health problems were mentioned once b r i e f l y i n one sentence on h i s assessment along with two words "marital discord" to describe the state of his r e l a t i o n s h i p with his wife. Two paragraphs of t h i s assessment however, were written on h i s p s y c h i a t r i c 9 8 diagnosis (Axis I-Depression) and on his medication regimen of anti-depressant and anti-anxiety drugs. Upon hi s discharge from hospital and r e f e r r a l to the Mental Health Team, Mr. L. was faced with a s i m i l a r scenario. During his f i r s t assessment by a p s y c h i a t r i s t and nurse, the main theme of the interview exclusively related to whether or not h i s anti-depressant medication should be increased. Mr. L. commented that although at f i r s t he did not know what to expect from h i s f i r s t v i s i t at the team, he soon r e a l i z e d that " t h i s was the exact same gig as at the h o s p i t a l " . Mr. L.'s case of depression i l l u s t r a t e s how psychiatry through ho s p i t a l based and community services f a i l s to address the larger s o c i o - p o l i t i c a l issues r e f l e c t e d i n i n d i v i d u a l cases of deviance by attempting to i s o l a t e and control i t s symptomatology through bio-medical technology such as drug therapy. Refusal of services from other agencies Deviance i n the e l d e r l y i s co n t r o l l e d through a number of services other than mental health. These mainly include medical services such as health c l i n i c s or personal physicians, and home support services. I t appears that r e f u s a l of a given service or uncooperativeness to i t was a s u f f i c i e n t reason to motivate the d i s t r i b u t o r of such services to r e f e r t h e i r c l i e n t for p s y c h i a t r i c assessment. Two such cases (3 percent) were 99 i d e n t i f i e d i n the r e f e r r a l form sample. One r e f e r r a l was made by a long term care assessor on the grounds that her c l i e n t had been ver b a l l y abusive towards the homemakers she had sent i n to help him clean h i s apartment, and also had been uncooperative towards the service by not being i n his apartment when the homemakers were scheduled to come i n . She subsequently withdrew the services and sent her c l i e n t a l e t t e r t e l l i n g him he had been referred to the Mental Health Team for p s y c h i a t r i c assessment. The second r e f e r r a l was made by the Public Trustee for an e l d e r l y woman because she had refused support services to help her keep her room clean and because she had not been compliant i n taking her medications. I t seems therefore that some professionals tend to ascribe mental i l l n e s s i n c l i e n t s who turn down the services offered to them. The reason behind such behavior i s uncertain but one could venture that these professionals possibly believe that t h e i r services are so e s s e n t i a l to the e l d e r l y that no one i n t h e i r r i g h t mind would refuse them. The use of mental health services therefore i s oriented towards increasing the compliance of c l i e n t s towards the services they do not want. This i n t r u s i o n of psychiatry i n the delivery of non-mental services to the e l d e r l y could e f f e c t i v e l y prevent them from complaining about the poor q u a l i t y of a service, or refusing i t i f they f e e l they don't need i t , without being exposed to the r i s k of being l a b e l l e d 100 mentally i l l . In fact, t h i s r i s k may already be a r e a l i t y as demonstrated i n the next section. Complaining A number of r e f e r r a l forms (N = 5, 8 percent) c i t e d complaining behavior as a reason for r e f e r r a l . In one case, an apartment manager referred an e l d e r l y woman a f t e r she had written him many l e t t e r s of concern regarding the running of the apartment building. The g e r i a t r i c i a n who took the r e f e r r a l wrote: Mrs. E.B., a 74 year old resident of Towers, was referred by the manager as he f e l t that her plethora of l e t t e r s of concern were now becoming of such a nature that they warranted p s y c h i a t r i c assessment. S p e c i f i c a l l y , there was a ce r t a i n paranoid theme now developing to her l e t t e r s which he wished us to investigate. The manager stopped short of proposing a diagnosis for t h i s woman's condition, but possibly that of 'Acute Complaining Disorder' would have been adequate. Unfortunately for him, the g e r i a t r i c i a n did not agree with his assessment and f e l t she did not warrant p s y c h i a t r i c intervention. Other "complaint r e f e r r a l s " were r e l a t i v e l y s i m i l a r i n nature. One el d e r l y man had been referred a f t e r he had been accusing neighbors i n other apartment suites of bothering him, and writing l e t t e r s of complaints about i t to the management of the building who f e l t that such complaints were u n j u s t i f i e d and required an assessment for "paranoid, depressed, or demented behavior." In another case, the 101 Police Department referred a woman who had repeatedly been c a l l i n g them to complain about other tenants i n her build i n g . One more r e f e r r a l was made by a general p r a c t i t i o n e r who f e l t that one of his patients needed counselling f or numerous psychosomatic complaints. She would often c a l l his o f f i c e with complaints about her bowels of which medical investigations revealed no pathology. One cannot help but draw p a r a l l e l s between complaining and refusing services as forms of deviance. I t appears that the expected normative behavior here i s for the e l d e r l y to accept what i s given to them i n terms of services without c r i t i c i z i n g i t . Complaining about a service or refusing i t contradicts the passive r o l e of receiver which the el d e r l y are often assigned by society. The reaction has been to attempt to deal with such behavior by int e r p r e t i n g i t as another form of deviance, that of mental i l l n e s s , which can then be dealt with by more c o n t r o l l i n g services such as mental health or the p o l i c e . Causing a disturbance Causing a disturbance i s a term which serves to describe behaviors i d e n t i f i e d by r e f e r r i n g agents as disruptive and/or offensive to them, or to other people. Eight percent (N = 5) of the r e f e r r a l forms included public disturbance as reason for r e f e r r a l . Some of these included one e l d e r l y woman who had been preaching i n the c a f e t e r i a of a hotel and d i s t r i b u t e r e l i g i o u s l i t e r a t u r e on the streets; 102 a 70 year old man who had been banging on the walls of his apartment, disturbing other tenants i n the building; an 87 year old woman who was y e l l i n g o f f her balcony; and f i n a l l y an aged woman who was observed picking food scraps out of a "Smithright" garbage bin and sleeping i n lane a l l e y s . On t h i s l a s t case, team s t a f f made a couple of "home v i s i t s " but were unsuccessful i n locating her. In those cases, the e l d e r l y who created a disturbance were at t r i b u t e d the status of mentally i l l . However, i t would be i n t e r e s t i n g to compare s i m i l a r behaviors i n younger people to see i f a s i m i l a r a t t r i b u t i o n would be e l i c i t e d i n the r e f e r r i n g agents. I suspect that a r e f e r r a l to the l o c a l p o l i c e department would more often be the chosen course of action for the younger deviants. An important factor which may serve to elucidate the propensity of agents to ascribe mental i l l n e s s i n these cases, i s the fact that three out of the f i v e r e f e r r i n g agents had previous contact with the g e r i a t r i c s p e c i a l i s t at the Team. They were part of h i s "early warning system". The other two r e f e r r a l s were i n d i r e c t r e f e r r a l s i n the sense that the ind i v i d u a l s r e f e r r i n g had not d i r e c t l y witnessed the behavior for which the e l d e r l y had been referred, but were passing on a r e f e r r a l made to them by the person who o r i g i n a l l y had witnessed that behavior. The o r i g i n a l or primary r e f e r r i n g agents were lay people who i n a l l l i k e l i h o o d had no previous knowledge or dealings with the g e r i a t r i c services of the mental health team. 103 In one of the cases, an e l d e r l y man had been observed banging on the walls of h i s apartment keeping other residents awake at night. The primary agent i n t h i s case, the apartment manager, referred him f i r s t to the p o l i c e department who i n turn made a r e f e r r a l to the Team. In the second case, an e l d e r l y woman had been observed eating out of a garbage bin and sleeping i n the a l l e y at night. A resident of the area o r i g i n a l l y phoned the Ministry of Soci a l Services and Housing to enquire i f anything could be done to help t h i s woman. I t was the s o c i a l worker at the Ministry who l a t e r phoned the Mental Health Team. These cases i l l u s t r a t e that awareness of and/or previous contact with the Mental Health Team i s a factor which makes a given witness of deviance i n the aged more l i k e l y to a t t r i b u t e mental i l l n e s s and consequently i n i t i a t e a r e f e r r a l to the Team. More s p e c i f i c a l l y , i t i s related to t h e i r previous contact with the g e r i a t r i c s p e c i a l i s t on that team. People without p r i o r knowledge of the Team tended to re f e r to other non-mental health services such as the pol i c e or M.S.S.H. presumably because they d i d not a t t r i b u t e the deviant behavior they observed to mental i l l n e s s . Problems of Liv i n g and Mental I l l n e s s One of the hypotheses of the study i s that psychiatry tends to control an increasingly wider range of deviance by broadening the concept of mental i l l n e s s to include many 104 problems of l i v i n g . In t h i s l a s t chapter, I have shown how community agents contribute to t h i s tendency by i d e n t i f y i n g these problems as symptomatic of mental i l l n e s s i n the e l d e r l y who then are referred to the Mental Health Team for treatment. In some cases, problems of l i v i n g , e.g., poor hygiene, are i n d i c a t i v e of an underlying brain dysfunction which can impair the i n d i v i d u a l ' s a b i l i t y to care for himself as i n the case of Mr. W. However, i n many other cases, these problems of l i v i n g are j u s t that, problems in d i v i d u a l s encounter i n t h e i r l i v e s and which they deal with i n the best manner they know. I t can be the case of Mrs. S. who suffered from an urinary t r a c t i n f e c t i o n and decided to remain i n her room for fear of voiding h e r s e l f i n public as she did previously at the home's chapel. Yet that problem was described by the nurse i n charge of the home as paranoid behavior, a p s y c h i a t r i c disorder characterized by a fear of people. Other forms of deviance, e.g., criminal behavior, can also be redefined as mental i l l n e s s as i n the case of Miss D. whose habit of breaking into parked cars, which i s a criminal offense, became a symptom of brain dementia when le g a l a u t h o r i t i e s were faced with the d i f f i c u l t i e s of sending a 73 year old woman to prison for repeatedly f a i l i n g to appear i n court on her charges. S i m i l a r l y , i n the case of Mr. M. , whose Huntington's disease and lack of motor control made him a l i a b i l i t y for nursing s t a f f due to h i s arms f l y i n g about uncontrollably, 105 i t was a medical condition that was transformed into mental i l l n e s s . At times, the deviance referred to the Team says more about the r e f e r r i n g agent's motive than about the nature of the psychopathology i t s e l f . However, the tendency of community agents to medicalize problems of l i v i n g does not appear to be inherently motivated but rather i t i s very much the r e s u l t of the e f f o r t s by the g e r i a t r i c i a n to educate them i n recognizing the signs and symptoms of mental i l l n e s s while increasing t h e i r awareness of the Mental Health Team's capacity to deal with such i l l n e s s . In the next chapter, I explore i n more depth the ro l e of the Team, i n medicalizing deviance i n the el d e r l y . 106 CHAPTER 5 MEDICALIZING DEVIANCE: THE ROLE OF THE COMMUNITY MENTAL HEALTH TEAM In chapter four, I described the process by which e l d e r l y people i n the community are referred for p s y c h i a t r i c services to the Mental Health Team by various r e f e r r i n g agents. In t h i s chapter, I w i l l further analyze t h i s process to reveal that the mental health team, and more s p e c i f i c a l l y i t s g e r i a t r i c s p e c i a l i s t , are active contributors to the process by which r e f e r r i n g agents i d e n t i f y and sanction mental i l l n e s s i n the e l d e r l y . This contribution takes the form of the g e r i a t r i c i a n aggressively promoting g e r i a t r i c mental health services to various community agents who regularly come i n contact with the e l d e r l y . Agents range from highly trained health care professionals e.g., nurses, to lay people without s p e c i f i c knowledge about the eld e r l y , e.g., apartment manager. The purpose of t h i s promotional e f f o r t i s to educate and s e n s i t i z e community agents to the signs and symptoms of mental i l l n e s s as defined by the p s y c h i a t r i c model. His aim i s to create a network of amateur diagnosticians functioning within the bio-medical framework who are trained to recognize and r e f e r mental i l l n e s s . This i s what the team's g e r i a t r i c i a n refers to as his "early warning system". Its purpose i s to ensure a continuous flow of c l i e n t r e f e r r a l s to the team, hence creating and perpetuating a demand for a 107 g e r i a t r i c s p e c i a l i s t ' s p o s i t i o n within that team. Hence, deviance as mental i l l n e s s i n the e l d e r l y becomes a commodity which benefits both the Mental Health Team and the g e r i a t r i c i a n . PROMOTING GERIATRIC MENTAL HEALTH SERVICES IN THE COMMUNITY:  THE ROLE OF THE GERIATRIC SPECIALIST The f a m i l i a r i t y of many of the r e f e r r i n g agents with g e r i a t r i c services the Team has to o f f e r them seems to indicate that the g e r i a t r i c s p e c i a l i s t i s an active contributor to the l a b e l i n g of deviance i n the e l d e r l y population. The p o s i t i o n of g e r i a t r i c s p e c i a l i s t (also referred to as that of g e r i a t r i c i a n i n text) was created i n 1983. Despite the existence of s i x other teams i n the organization, the investigated team was the only one to receive that p a r t i c u l a r designation. Two p o l i t i c a l factors account for t h i s . F i r s t , the Team serves a catchment area which has the highest concentration of e l d e r l y of any of the areas served by the other teams. Concomitant to t h i s factor was the g e r i a t r i c i a n ' s own i n t e r e s t i n the e l d e r l y which resulted i n him receiving a l l r e f e r r a l s of older people to the Team. Other workers with one exception had l i t t l e i f no i n t e r e s t i n providing treatment to that group. Some i n fact p o s i t i v e l y stated that they would hate to work with older people and i n fact 108 were glad that they had one worker on t h e i r team to deal with them. The g e r i a t r i c i a n started to advocate to h i s superiors both within the Team and at the administrative l e v e l which oversees a l l teams, for the creation of a s p e c i a l i s t ' s p o s i t i o n . He made h i s requests known about 2 years before i t s actual creation. Concomitantly, the g e r i a t r i c i a n , who was then a regular worker, was carving h i s s p e c i a l i t y by acquiring his caseload of most i f not a l l e l d e r l y c l i e n t s referred to the Team, and by networking with various community agencies providing services to the aged, making them aware of h i s presence on the Team and of h i s p a r t i c u l a r i n t e r e s t so they could r e f e r people they f e l t needed p s y c h i a t r i c care. This promotional e f f o r t served to increase the number of el d e r l y r e f e r r a l s to the team, hence creating a need for a s p e c i a l i s t ' s p o s i t i o n . His demands 1 were f i n a l l y met i n 1983. The g e r i a t r i c i a n ' s promotion of h i s services was aimed at various l e v e l s of community agents ranging from lay people to professionals i n management positions who o f f e r some form of service to the e l d e r l y . The services targeted can be divided i n two general categories: r e s i d e n t i a l services and support services. Residential services r e f e r to a l l services directed at housing to the e l d e r l y . These ranged from residences, with minimal supervision such as apartment buildings or hotels, to semi-supervised residences such as government subsidized 109 h o u s i n g p r o j e c t s f o r s e n i o r s , and f u l l y s u p e r v i s e d f a c i l i t i e s s u c h a s n u r s i n g homes. S u p e r v i s i o n i s e n s u r e d i n t h e f i r s t c a s e , b y go v e r n m e n t h i r e d c a r e t a k e r s a n d / o r a p a r t - t i m e n u r s e ; and i n t h e l a s t c a s e , by f u l l - t i m e n u r s i n g s t a f f . A l l o f t h e s e i n d i v i d u a l s were i d e n t i f i e d i n t h e r e f e r r a l f o r m sample and i n t h e c a s e s t u d y s a mple as common r e f e r r i n g a g e n t s o f e l d e r l y p e o p l e t o t h e m e n t a l h e a l t h team. S u p p o r t s e r v i c e s r e f e r t o any s e r v i c e s w h i c h a r e n o t d i r e c t l y i n v o l v e d w i t h p r o v i d i n g a r e s i d e n c e t o t h e e l d e r l y b u t do i n some way s u p p o r t them i n t h e i r d a i l y a c t i v i t i e s . T h e s e a r e : l o n g t e r m c a r e s e r v i c e s w h i c h p r o v i d e e l d e r l y w i t h home s u p p o r t ; t h e M i n i s t r y o f S o c i a l S e r v i c e s & H o u s i n g f o r f i n a n c i a l a s s i s t a n c e ; g e n e r a l p r a c t i t i o n e r s who s e e e l d e r l y i n t h e i r p r a c t i c e , and v a r i o u s s e n i o r ' s o r g a n i z a t i o n s o f f e r i n g p r o g r a m s r a n g i n g f r o m b i n g o n i g h t t o p e e r c o u n s e l l i n g . F i n a l l y t h i s c a t e g o r y a l s o i n c l u d e s o t h e r a g e n c i e s w h i c h a r e n o t s p e c i f i c a l l y i n v o l v e d w i t h t h e e l d e r l y b u t c a n p r o v i d e them w i t h some s e r v i c e s . T h e s e a r e t h e P o l i c e D e p a r t m e n t , and v a r i o u s s o c i a l s e r v i c e s a g e n c i e s . S t a f f w o r k i n g i n s u p p o r t s e r v i c e s h a v e a l s o c o n s i s t e n t l y a p p e a r e d a s r e f e r r i n g a g e n t s on b o t h t h e sample o f r e f e r r a l f o r m s o r i n t h e c a s e s t u d i e s . T h e r e f o r e , i t a p p e a r s t h a t t h e r e i s a t an i n f o r m a l l e v e l a s t r o n g c o r r e l a t i o n between t h e g e r i a t r i c i a n ' s p r o m o t i o n o f h i s s e r v i c e s t o s t a f f i n e l d e r l y s e r v i c e s and t h e i r p r o p e n s i t y t o r e f e r e l d e r l y p e o p l e t o t h e Community M e n t a l H e a l t h Team 110 for p s y c h i a t r i c services. For example, i n a l l f i v e case studies, each of the r e f e r r i n g agents had had previous contact with the g e r i a t r i c i a n from previous r e f e r r a l s made to the team regarding e l d e r l y people. Three out of the f i v e r e f e r r i n g agents knew s p e c i f i c a l l y of the existence of the g e r i a t r i c s p e c i a l i s t on the Mental Health Team and only one agent knew of his status as a mental health worker but did not know of his s p e c i a l i s t p o s i t i o n . F i n a l l y , one case was referred to a worker other than the g e r i a t r i c s p e c i a l i s t but who also took an i n t e r e s t i n working with the e l d e r l y . The c o r r e l a t i o n between promotional e f f o r t s and the sample of r e f e r r a l forms analyzed i n the study was more d i f f i c u l t to ascertain. The breakdown of t h i s sample of r e f e r r i n g agents by occupation i s given i n Table V. In reviewing these r e f e r r a l forms i n d i v i d u a l l y and ascertaining the i d e n t i t y of each of the r e f e r r i n g agents, I concluded that at least 62 % of these agents (N = 40) had been approached p r i o r to t h e i r r e f e r r a l by the g e r i a t r i c i a n i n some form of promotion. The i d e n t i t y of these agents was known to me from my nine months of f i e l d work at the Team during which time I had either personal contact with these agents, or was able to confirm t h e i r i d e n t i t y with the g e r i a t r i c i a n himself. A prime example of the impact of the promotional e f f o r t s i s the case of professionals working for Long Term Care which provides home support to the disabled e l d e r l y . The l e v e l of care provided i s determined by assessors who I l l Table V Breakdown of Referring Agents by Occupation (N = 65) N 4 1. P r o f e s s i o n a l s i n oth e r s e r v i c e s than mental h e a l t h (e.g., MSS&H workers; LTC c a r e workers) 18 28 2. P r o f e s s i o n a l i n mental h e a l t h s e r v i c e s (e.g., nurse on p s y c h i a t r i c ward) 9 14 3. Apartment Managers 11 17 4. General P r a c t i t i o n e r 10 15 5. N u r s i n g home s t a f f 4 6 6. S e l f 4 6 7. R e l a t i v e or f r i e n d 6 9 8. P o l i c e _3 _5 T o t a l 65 100% 112 v i s i t the e l d e r l y at home and have regular contact with them throughout the period of time they require assistance. Therefore, because of t h e i r front l i n e p o s i t i o n , they are primary candidates for i d e n t i f y i n g people who could require p s y c h i a t r i c service - and thus to be part of the Team's "early warning" system. The promotional e f f o r t s targeted to t h i s group consisted of the g e r i a t r i c i a n attending monthly meetings of a l l the assessors and t h e i r supervisors working i n the catchment area of the Team. During the f i r s t few meetings of the sort, the g e r i a t r i c i a n gave a description of the Team and of the s p e c i a l i z e d services he offered. Further attendance at these meetings became somewhat symbolic as l i t t l e information was exchanged between him and the assessors. However, his presence continued to reinforce the existence of the g e r i a t r i c service to the assessors, and p e r i o d i c a l l y when a new assessor would a r r i v e on s t a f f , they would then be promptly informed of such services. Referrals by LTC assessors, which were c l a s s i f i e d under the category "Professionals i n services other than mental health", to t a l e d 12 percent (N = 8) of a l l r e f e r r a l s for the year 1987, which i s the second largest source of r e f e r r a l s from professionals, the f i r s t one being general p r a c t i t i o n e r at 15 percent (N = 10), and the t h i r d largest o v e r a l l source of r e f e r r a l from a single service group, the f i r s t one being apartment managers at 17 percent (N = 11). Of course, these percentages would be more s i g n i f i c a n t i f they were compared to the percentage of r e f e r r a l s by 113 these agents p r i o r to t h e i r being approached by the g e r i a t r i c i a n . Alas, such percentages were not tabulated due to the l i m i t e d time available for the completion of the study. However, comments by the g e r i a t r i c i a n indicated that since h i s a r r i v a l on the Team, there has been a marked increase i n the r e f e r r a l s of e l d e r l y people to the Team, and more s p e c i f i c a l l y of r e f e r r a l s by the three categories of agents above mentioned. Perhaps the most s i g n i f i c a n t of such an increase i s that of apartment : managers, who form the single most important single group of r e f e r r i n g agents. As a group, they were heavily targeted by the g e r i a t r i c i a n as a source of r e f e r r a l since most e l d e r l y i n the team's catchment area l i v e i n apartment buildings. Again i t i s not known what percentage of r e f e r r a l s came from apartment managers p r i o r to the presence of the g e r i a t r i c i a n on the Team. However, one could expect that most apartment managers would not be aware of s p e c i a l i z e d g e r i a t r i c mental health services i n the area, l e t alone be able to determine when an e l d e r l y person would be i n need of- such service. They have l i t t l e contact with professionals i n health services, and usually disturbances or problematic tenants are handled through a r e f e r r a l to a better known service, the p o l i c e department. Yet, apartment managers made for 17 percent of a l l r e f e r r a l s to the Team, higher even than professional groups who were most aware of the Team's existence such as LTC assessors and general p r a c t i t i o n e r s . Their presence as r e f e r r i n g agents 114 i s a testimony to the effectiveness of the g e r i a t r i c i a n ' s promotional e f f o r t s ; He singled them out as one of- the most important groups for his "early warning system" because of t h e i r front l i n e p osition, not unlike that of LTC assessors. Many times during my f i e l d work, when on home v i s i t s to an e l d e r l y c l i e n t of the Team l i v i n g i n apartments, I was struck by the f a m i l i a r i t y and f r i e n d l i n e s s e x i s t i n g between the s p e c i a l i s t and many of the apartment managers. Often, when a c l i e n t was reluctant to l e t him come i n the building, the g e r i a t r i c i a n would simply ri n g the manager of the bui l d i n g who would r e a d i l y l e t him i n . In some cases, he would consult with some managers i n regards to referred c l i e n t s , asking questions regarding t h e i r behavior, the cleanliness of t h e i r suites, etc, hence, gathering data which would then be used to help him formulate a diagnosis. Overall then, one can conclude that the g e r i a t r i c i a n ' s promotional e f f o r t s i n the l a s t f i v e years or so since his entrenchment as a s p e c i a l i s t for the e l d e r l y within the Community Mental Health Team have resulted i n an increase of e l d e r l y c l i e n t s referred by both professionals and non-professional agents who were s p e c i f i c a l l y targeted by such e f f o r t s . These promotional e f f o r t s also contributed to medicalize the type of deviance i d e n t i f i e d by community agents, hence, making i t possible for them to re f e r e l d e r l y c l i e n t s to the mental health system which otherwise would have been directed to other services, e.g., p o l i c e . In the next section, I w i l l discuss the consequences of t h i s 115 medicalization of deviance for the e l d e r l y l i v i n g i n the community. MEDICALIZATION: TRANSFORMING DEVIANCE INTO MENTAL ILLNESS The g e r i a t r i c i a n i s a key actor i n influencing community r e f e r r i n g agents to transform deviance i n the e l d e r l y into mental i l l n e s s which then can be controlled by the Mental Health Team. This influence i s very much related to h i s t r a i n i n g which i s rather unusual for t h i s type of work. He did combined undergraduate studies i n both sociology and biology and then furthered h i s education by taking a diploma course i n gerontology at Simon Fraser University. He then obtained r e g i s t r a t i o n with the Board of Soci a l Workers. He u t i l i z e s the l e t t e r s R.S.W. af t e r his name on h i s business cards, which stands for Registered So c i a l Worker. His professional interests do not l i e necessarily with the e l d e r l y as a disadvantaged people, nor does he p a r t i c u l a r l y i d e n t i f y himself with t h e i r p o l i t i c a l struggle or even with t h e i r personal struggle, whether i t be with personal growth or family issues. Rather, h i s interests are of a more diagnostical nature. As he mentioned to me, what he enjoyed most about working with the elde r l y , i s not so much who they are as people, but more the type of problems they present. He i s a n a l y t i c a l and deductive i n his way of looking at a given 116 problem, very much i n the bio-medical t r a d i t i o n . In fact, he often re f e r s to himself as a "diagnostician" and prides himself i n being able to c o r r e c t l y i d e n t i f y the appropriate p s y c h i a t r i c diagnosis for h i s c l i e n t s , which he then often compares to the c l i n i c a l impressions of h i s p s y c h i a t r i s t colleagues. This a b i l i t y i s for him a source of professional s a t i s f a c t i o n . In fact, he once declared to me that at one time, his ambition was to become a p s y c h i a t r i s t . Well, i n many ways, he i s one. Therefore, what we have here i s a mental health worker functioning very much within the bio-medical model who s p e c i a l i z e s with the e l d e r l y population. His promotional e f f o r t s consist of a f i r s t step to make community agents aware of the existence of h i s s p e c i a l i z e d services at the Mental Health Team; and secondly to educate them about the common p s y c h i a t r i c disorders i n the e l d e r l y and how to recognize the signs and symptoms of such disorders. Such educational processes tend to vary i n complexity depending on the l e v e l of professionalism displayed by these agents. An apartment manager for example, may be asked to phone the Team i f he or she f e e l s that the e l d e r l y person i s behaving i n unusual ways whereas a nurse working for the Long Term Care system may be given more information as to which behaviors are i n d i c a t i v e of mental i l l n e s s . Hence, the g e r i a t r i c i a n e f f e c t i v e l y created through t h i s process a network of amateur diagnosticians who l i k e himself, are 117 trained within the bio-medical framework to recognize and re f e r deviance as mental i l l n e s s . What are the consequences of the existence of t h i s network for the e l d e r l y l i v i n g i n the community? The network can re f e r forms of deviance which i n some cases t r u l y require medical attention, e.g., stroke patient s u f f e r i n g from an Organic Brain Syndrome, but i n other cases, i t can i d e n t i f y deviance which f a l l s more i n the category of "problems of l i v i n g " . The concept of problems of l i v i n g r elates to the notion that mental i l l n e s s i s not i l l n e s s but a bogus invention that allows behavior, any behavior, to be categorized as disease. As Szasz (1970) puts i t : When I assert that mental i l l n e s s i s myth, I am not saying that personal unhappiness and deviant behavior do not ex i s t . The expression "mental i l l n e s s " i s a metaphor that we have come to mistake for a fact . . . we c a l l people mentally i l l people when t h e i r personal conduct v i o l a t e s c e r t a i n e t h i c a l , p o l i t i c a l , and s o c i a l norms . . . But the mental i l l n e s s metaphor a c t u a l l y prevents us from understanding the behaviors c a l l e d "mental i l l n e s s " for what they are: problems of l i v i n g , p. 21. Although the purpose of t h i s study i s not to determine what i s true mental i l l n e s s and what i s not i n the referred cases, i t i s important to recognize that some of the ind i v i d u a l s observed were su f f e r i n g from medical conditions a f f e c t i n g t h e i r brain function hence producing the deviant behaviors, e.g., confusion, d i s o r i e n t a t i o n , which prompted the agents to ref e r them to the team; however, i n many cases r e f e r r a l s were i n i t i a t e d f or behaviors which although 1 1 8 presented as mental i l l n e s s , have more to do with either other forms of deviance, e.g., crime, or with incompatibility between the referred person and his or her r e f e r r i n g agents. To i l l u s t r a t e t h i s point, l e t us take the cases of Mr. W. and Miss D. , who had been both referred to the Team because of t h e i r demented behaviors. In the case of Mr. W. the behaviors which prompted his r e f e r r a l to the team included amongst other things a lack of personal hygiene. Hygiene neglect i s i n i t s e l f i n our society a f a i r l y d r a s t i c departure from the given s o c i a l norms of cleanliness. In other words, people who smell bad and wear d i r t y clothes are quite noticeable and e a s i l y labeled. Mr. W.'s clothes were stained and smelled. He had large nicotine stains on his fingers, h i s h a i r was greasy, and he was perpetually unshaven. Other deviant behaviors i d e n t i f i e d were his lack of orientation to time and place, also very noticeable departures from s o c i a l norms. Therefore, from t h i s b r i e f analysis of Mr. W.'s deviance, one could conclude that mental i l l n e s s here i s r e a l l y a s e r i e s of "problems of l i v i n g " which transgress c e r t a i n norms rather than a p s y c h i a t r i c i l l n e s s . However, further medical inves t i g a t i o n using a brain scan i n facts, confirmed h i s p s y c h i a t r i c diagnosis. His brain showed s i g n i f i c a n t damage i n c e r t a i n areas which are responsible for the cognitive s k i l l s necessary for o r i e n t a t i o n or taking care of one's s e l f . 1 1 9 So, i n t h i s case, deviant norm breaking behavior served as an indicator of an underlying i l l n e s s not d i r e c t l y v i s i b l e but nevertheless present. A r e f e r r a l to the Mental Health Team could be considered appropriate as Mr. W. required medical intervention to address his condition. This case also speaks i n favor of the g e r i a t r i c i a n ' s early warning system where a community agent who he previously approached, made what could be considered here to be an "appropriate" r e f e r r a l . However, many cases observed were more representative of what Szasz described as problems of l i v i n g being transformed into mental i l l n e s s . Consider the case of Miss D. who was referred to the Team by a s o c i a l worker from a government funded s o c i a l service agency which deals with d i f f i c u l t non-compliant c l i e n t s . Miss D. had been referred to that agency by her probation o f f i c e r because she had been arrested by the po l i c e for breaking into cars, and also f a i l e d to appear i n court on her charges. Because of her age, 73, her probation o f f i c e r was reluctant to issue a warrant and send her to prison u n t i l the date of her court appearance. The probation o f f i c e r and the s o c i a l worker at the agency were at a loss to explain the motive behind her criminal act since she had been working as a c l e r k i n a large h o s p i t a l u n t i l her retirement at age 65 and she was receiving nine hundred d o l l a r s of pension money every month. So, money could not be the motive. Furthermore, she had 120 been observed doing other unusual things i n the past. She had been reported sleeping on an abandoned couch i n a street a l l e y , and foraging for food i n a "Smithright". Her hygiene although not grossly neglected was not the best. Her clothes were old and not exactly i n fashion and her ha i r was disheveled. F i n a l l y , she had a continuous tremor of her head over which she had l i t t l e control and also claimed that as a c h i l d she had been h i t over the head by a baseball bat. So, they concluded based on the above information that Miss D. must be su f f e r i n g from dementia. A r e f e r r a l was made to the team to investigate her dementia. The g e r i a t r i c i a n paid t h i s woman a home v i s i t . He conducted a f u l l p s y c h i a t r i c assessment and stated i n his report: "I would detect no evidence of a dementing process nor delirium. Further there was no disturbance i n form or content of thought or perception, nor was there gross disturbance i n negative signs. I f e e l , however, that there i s a chronic impairment in her judgement and insight with respect to her constantly entering into parked cars". Notice here the rather profuse use of p s y c h i a t r i c jargon, which i s somewhat t y p i c a l of h i s s t y l e of assessment report. What i s said here i s that Miss D. i s p e r f e c t l y sane although she should know better than going around breaking into parked cars. In fact, t h i s e l d e r l y woman had been referred on three previous occasions to the Team for s i m i l a r reasons and each time, she was found ". . . not amenable to ps y c h i a t r i c intervention". 121 So, as opposed to Mr. W., the case of Miss D. i s one of "problems of l i v i n g " , i n t h i s case criminal behavior, along with other less prominent problems, e.g., somewhat neglected hygiene and an unusual l i f e s t y l e , which seem to have been confirmed as such even by the g e r i a t r i c i a n . The r e f e r r a l of Miss D. r e f l e c t s the negative aspect of the g e r i a t r i c i a n ' s early warning system which, by helping the community to medicalize deviance, tends to foster the use by people of the stereotype of the e l d e r l y as senile i n d i v i d u a l s to explain norm breaking behavior. This tendency i s further evidenced by reviewing the behaviors e a r l i e r i d e n t i f i e d for which e l d e r l y people get referred to the team. For example, eight percent (N = 5) of the r e f e r r a l forms c i t e d complaining i n one form or another as the reason for r e f e r r a l . In one case, one apartment manager j u s t i f i e d r e f e r r a l because he had noticed "a c e r t a i n paranoid theme" developing i n the l e t t e r s of complaints he was receiving from one of the residents. What i s important to notice here i s that apartment managers do not as a rule, analyze t h e i r l e t t e r s of complaints to determine whether or not the person writing them i s s u f f e r i n g from a paranoid disorder. Yet, t h i s uncommon use of p s y c h i a t r i c jargon i s i n d i c a t i v e of how lay people who have been approached by the g e r i a t r i c i a n have become se n s i t i z e d to the psychiatry framework of mental i l l n e s s . One could expect the Mental Health Team, and more s p e c i f i c a l l y i t s g e r i a t r i c i a n , to be c a r e f u l as to not 122 involve i n p s y c h i a t r i c care e l d e r l y who have been inappropriately referred and that do not present with s i g n i f i c a n t psychopathology as i n the previously mentioned case of Miss D. After a l l , the organization under which the Team operates s p e c i f i c a l l y states i n i t s p o l i c y and procedure manual that "as a f i r s t p r i o r i t y , [ i t ] provides treatment to seriously mentally i l l adults . . . " However, t h i s i s not the case necessarily as the g e r i a t r i c i a n also operates under the constraint of the a v a i l a b i l i t y of deviance i n the e l d e r l y referred to the team necessary to j u s t i f y h i s po s i t i o n as a s p e c i a l i s t . Such a po s i t i o n brings him both status amongst h i s peers as well as increased salary. Hence, the more mentally i l l e l d e r l y referred to the Team, the better for him. However, the supply of t r u l y demented people referable to the Team such as the case of Mr. W. i s rather li m i t e d . Furthermore, t r u l y demented e l d e r l y are not amenable to psychotherapy or r e h a b i l i t a t i v e p s y c h i a t r i c care because of the usually degenerative organic nature of the i l l n e s s . Therefore, there i s a need for the g e r i a t r i c i a n to f i n d other forms of mental i l l n e s s among the cases referred to him. Most of these as said e a r l i e r belong to the category of problems of l i v i n g not r e a l l y p s y c h i a t r i c care, a fact even recognized by the g e r i a t r i c i a n himself (as i n the case of Miss D.). But what i f there i s a means of transforming these problems ,. of l i v i n g into c l i n i c a l l y v a l i d mental 123 i l l n e s s ? This i s where medicalization of deviance operates at i t s best. To i l l u s t r a t e t h i s point, l e t us take again the case of Miss D. who was assessed to show no sign of dementia or severe psychopathology. Therefore, how to j u s t i f y t h i s woman's attending the Team i f she i s not r e a l l y mentally i l l ? Ah but she i s . . . Her criminal a c t i v i t y of breaking into cars and rummaging through glove compartments for money can be explained i n p s y c h i a t r i c terms. This woman i s t r u l y s u f f e r i n g from a p s y c h i a t r i c disorder. Let's hear the g e r i a t r i c i a n expand on what Miss D. i s s u f f e r i n g from: G- "Some people [who are depressed], take t h e i r worthlessness to the extreme and a c t u a l l y harm themselves . . . Some people punish themselves i n less dramatic ways, some people w i l l commit crimes, small things, s h o p l i f t i n g i s the most common one, because you're pretty sure y o u ' l l be caught. This i s the way they f i n d society to punish them i n r e l a t i v e l y safe ways . . . I t occurs a l l the time when tr e a t i n g someone for depression". R- "So the case of D. - breaking into cars would be s i m i l a r to s h o p l i f t i n g i n these people? G- " I t could be. We do know she's not a f t e r the money and she does not vandalize the car . [and] she's got some losses. Her retirement . . . so she l o s t her job and both of her parents died very suddenly. She also had a s i s t e r married into an a f f l u e n t family and she has a brother who i s a b i t of an a l c o h o l i c who she worries about. There i s enough material there to think there would be a depression". And there you go, the g e r i a t r i c i a n reframed Miss D.'s problems into depression and concluded i n h i s assessment that: 124 There i s chronic impairment i n her judgement and insight with respect to her constantly entering into parked cars . . . [and] . . . although not c l i n i c a l l y •depressed, I f e e l there i s a chronic sadness within t h i s woman which would warrant psychotherapy. As a r e s u l t , the g e r i a t r i c i a n developed a treatment plan i n which he " w i l l develop further her hi s t o r y and involve a p s y c h i a t r i s t [and] l i a i s e with probation and the courts regarding her . . . treatment". And what was Miss D.'s perception of the g e r i a t r i c i a n ' s involvement i n her l i f e ? [It should be noted here that at t h i s point he had not t o l d her of h i s assessment, c l i n i c a l impression, or who he r e a l l y was - except to say that he would come to see her once i n a while] Let's see what she says: r - Do you know where M. [the g e r i a t r i c i a n ] works? D- No, I don't. r - The place i s act u a l l y c a l l e d the Mental Health Team. D- Well, i t seems kind of odd that he would be coming i n my d i r e c t i o n . You know . . . because there's nothing wrong with my mental health. r - You don't see yourself as mentally i l l ? D- No, I c e r t a i n l y don't [laugh]. I don't think I could go to Main St. and c o l l e c t three cheques and pay my rent and go out and get groceries and a l l the r e s t o f . i t . . . you know . . . and I mean i t doesn't sound l i k e there would be anything warped about that. This excerpt shows that Miss D. does not f e e l she needs to be involved with the Mental Health Team. However, things turned out d i f f e r e n t l y as the g e r i a t r i c i a n started to " l i a i s e " with her probation o f f i c e r and the courts, making 125 them aware that Miss D. was e f f e c t i v e l y i n need of mental health care because of her depression, the most l i k e l y cause of her deviant behavior. What happens next i s a good i l l u s t r a t i o n of the negative consequences for e l d e r l y people whose deviance i s medicalized by mental health a u t h o r i t i e s . Upon the request of Miss D's probation o f f i c e r , the Mental Health Team was used extensively to ensure that t h i s woman would present herself to court on her charges so she could be sentenced, an event which she had been successfully avoiding before our involvement. I was asked by the probation o f f i c e r i f I would volunteer my time to drive t h i s woman to court, which I did ( i t also provided me with a wonderful opportunity to interview my "subject" and observe the court procedures). Miss D. received a suspended sentence and the judge s p e c i f i c a l l y requested on her probation order that "under the d i r e c t i o n and supervision of a Probation O f f i c e r , [you] accept counselling as may be availab l e to you from time to time". The counselling the judge was r e f e r r i n g to was the Mental Health Team. He further recommended that i f Miss D. breached her probation order, a criminal act which would normally require her to appear i n court again and most l i k e l y to be sent to j a i l , she should not be brought i n front of him again. This request according to Miss D.'s probation o f f i c e r stemmed from the judge's b e l i e f that t h i s woman "should get [psychiatric] help . . . he f e l t [so] because of her age and the explanation she gave to the po l i c e which was somewhat 126 i r r a t i o n a l " . He added that " t h i s i s very unusual for a judge to do that. He i s very compassionate, very understanding . . . [and] doesn't want to put her i n prison." Hence, Miss D. was mandated by the terms of her probation order to "receive counselling", that i s to attend the Mental Health Team for p s y c h i a t r i c treatment despite the fa c t that t h i s woman was assessed to be s u f f e r i n g from no p s y c h i a t r i c disorder and that previous assessments i n 1983, 1986, and 1987 concluded that Miss D. "was not amenable to p s y c h i a t r i c intervention [and], i n fact, there was no psycho pathology severe enough to warrant our aggressive interventions". As an aside, a question can be asked about why Miss D's probation order read "accept counselling" rather than the more s p e c i f i c "attend the Mental Health Team", which was what the judge and her probation o f f i c e r wanted her to do during her probation period. The explanation was given to me by the g e r i a t r i c i a n . His organization's p o l i c y forbids r e f e r r a l s of c l i e n t who have been mandated through t h e i r probation order to attend a mental health team. The reason behind such p o l i c y i s that a team's services are voluntary and therefore, c l i e n t s should not be forced to receive treatment by them. One way to bypass t h i s p o l i c y i s to make the terms of a probation order vague enough so as not to mention the need for a c l i e n t to attend the Mental Health Team, but rather to state a need to receive counselling or therapy. P r i o r to 127 Miss D's appearance i n court her probation o f f i c e r and the g e r i a t r i c i a n t a c t a c i t l y agreed to request the judge not to be s p e c i f i c i n d i c t a t i n g the terms of h i s probation order. The judge complied to such a request as evidenced by the terms of Miss D.'s order, but nevertheless recommended ve r b a l l y to her that she attend the Mental Health Team. Hence, although she was under no l e g a l o b l i g a t i o n to receive p s y c h i a t r i c treatment, she was s k i l l f u l l y given the impression that she had to. The case of Miss D. i l l u s t r a t e s how the g e r i a t r i c i a n with the cooperation of other professionals can e f f e c t i v e l y engage e l d e r l y into receiving mental health care seemingly against t h e i r wish despite the voluntary nature of the service. This i s achieved through s k i l l f u l manipulation of the information given to them and of the p o l i c i e s and laws governing the services - whether l e g a l or p s y c h i a t r i c -which they come i n contact with during t h e i r career as deviants. The g e r i a t r i c i a n as a representative of the ps y c h i a t r i c profession tends to act as a powerful agent of s o c i a l c o n t r o l . His strength l i e s i n h i s a b i l i t y to transform the elder l y ' s problems of l i v i n g into mental i l l n e s s to j u s t i f y p s y c h i a t r i c intervention 'for t h e i r own good.' However, i t i s important to locate the g e r i a t r i c i a n ' s actions within the system i n which he operates. In doing so, one r e a l i z e s that as a professional, he responds to constraints s i m i l a r to those encountered by p s y c h i a t r i s t s 128 within the larger s o c i a l context. Interesting p a r a l l e l s can be drawn between those two l e v e l s of analysis, which I w i l l explore i n greater depth i n the next section. SOCIAL CONTROL AND MEDICALIZATION: THE ROLE OF THE  GERIATRIC SPECIALIST REVISITED So c i a l control and medicalization of deviance are concepts that go hand i n hand. So c i a l control can be conceptualized as "the means by which society secures adherence to s o c i a l norms; s p e c i f i c a l l y , how i t minimizes, eliminates, or normalizes deviant behavior" (Conrad, 1981, p. 7). The power of s o c i a l control comes from the authority the dominant class has to define c e r t a i n behaviors as norms to which members of society are expected to adhere to. Norm adherence i s then monitored and enforced through various i n s t i t u t i o n s such as the j u s t i c e system or the Church. Individuals who deviate from established norms can be subjected to various forms of control to ensure t h e i r return to normative behavior, or i f a l l else f a i l s , t h e i r removal from active l i f e within society. Such forms of control can range from a simple parking t i c k e t to a death sentence for example. Psychiatry i s considered here as an i n s t i t u t i o n of s o c i a l control which serves the i n t e r e s t s of the dominant cl a s s , while by the same token securing for i t s members a p r i v i l e g e d p o s i t i o n within the class order of c a p i t a l i s t 129 society. P s y c h i a t r i s t s act as agents of s o c i a l control by transforming deviance into i n d i v i d u a l problems of pathology, hence e f f e c t i v e l y i s o l a t i n g i t for the s o c i a l context which contributes to i t s occurrence i n the f i r s t place. For example, by defining a troubled e l d e r l y as demented and sick, the focus i s placed on the problems of one aging person. What i s ignored are the s o c i a l conditions faced by that person: poverty, i n s u f f i c i e n t income, dangerous working conditions endured e a r l i e r i n l i f e , and the stigma and i s o l a t i o n r e s u l t i n g from l i v i n g i n a youth oriented society. A l l of these conditions can be contributors to the problems of l i v i n g a f f e c t i n g the e l d e r l y , and no amount of therapy can change that. What i s needed are p o l i t i c a l interventions to modify the p o l i t i c a l order perpetuating these conditions. However, p s y c h i a t r i s t s do not make money by doing r a d i c a l p o l i t i c s . Rather, t h e i r income i s dependent on fee-for - s e r v i c e refunds through a t h i r d party, usually private insurance schemes l i k e i n the United States, or state funded insurance, l i k e i n Canada. P s y c h i a t r i s t s are i n fact private entrepreneurs who function under the constraints of a c a p i t a l i s t economy where increased income depends on increased growth. Simply put, the more services rendered, the more fee refunds c o l l e c t e d . This not only creates an incentive to provide more services, but also to expand these services to new markets by devising new categories of i l l n e s s e s needing treatment. For that purpose, 130 p s y c h i a t r i s t s have become agents of s o c i a l control i n a var i e t y of non-medical settings such as the prison system, the armed forces, and the community. Another means by which medical professionals increase t h e i r income i s through s p e c i a l i z a t i o n (Evans, 1984). Specialized treatments such as those offered by p s y c h i a t r i s t s command higher fees-for-service and generate greater income, hence further securing t h e i r p r i v i l e g e d p o s i t i o n as members of the upper c l a s s . There i s also an inherent drive within the p s y c h i a t r i c profession to assert i t s status as a v a l i d and rigorously s c i e n t i f i c branch of medicine. P s y c h i a t r i s t s are trained as medical doctors and are thereby s o c i a l i z e d into the medical perspective i n dealing with the mentally disturbed. Recent discoveries i n the bio-chemical and genetic o r i g i n s of mental disorders have fostered renewed enthusiasm for the p o s s i b i l i t y of finding a medical solution to mental i l l n e s s . As a r e s u l t , p s y c h i a t r i s t s more than ever are becoming f u l l -fledge partners with other medical s p e c i a l i s t s to increase t h e i r professional status, hence moving further away from the p o l i t i c a l and s o c i a l models of mental i l l n e s s . Now, l e t s examine the p a r a l l e l s between the constraints faced by the g e r i a t r i c s p e c i a l i s t (also referred to the g e r i a t r i c i a n i n text) i n the exercise of h i s functions within the Mental Health Team, and those p s y c h i a t r i s t s have to conform to as agents of s o c i a l control. 131 F i r s t , the g e r i a t r i c i a n works i n an environment which i s bio-medical i n i t s orientation. The society which funds the Team he works for subscribes to the DSM-III-R nomenclature of mental disorders i n describing the type of c l i e n t e l e i t d e l i v e r s services to.. Its p o l i c y and procedure manual (reference withheld for c o n f i d e n t i a l i t y purposes) states that: 3.7 patients accepted for treatment w i l l l i k e l y have one of the following primary diagnosis: - Schizophrenia Disorders - Paranoids Disorders - A f f e c t i v e Disorders - Organic Mental Disorders - Personality Disorders - Disorders of Childhood and Adolescence. The manual further states that the services offered by the Team include "prompt p s y c h i a t r i c assessment and diagnosis; comprehensive treatment including p s y c h i a t r i c diagnosis, medication, and i n d i v i d u a l and group therapy; and outreach, where appropriate, to patients who have dropped out of treatment or are reluctant to s t a r t treatment." Therefore, the g e r i a t r i c i a n i s expected to function within the p s y c h i a t r i c model of mental i l l n e s s i n h i s work, and needs to be f a m i l i a r with the diagnostical categories of the DSM-III-R. Such expectations are further entrenched i n Team's everyday functioning as approximately 80 percent of i t s s t a f f are trained i n the p s y c h i a t r i c model either as p s y c h i a t r i s t s or p s y c h i a t r i c nurses. 132 The r o l e of the s t a f f i s mainly to assess either alone or with a p s y c h i a t r i s t , a patient's p s y c h i a t r i c disorder, and to determine the needed course of treatment. Treatment interventions are invari a b l y focused on the ind i v i d u a l patient requiring assistance rather than looking at the conditions within the community which made such assistance necessary. Description of a worker's r o l e i n the p o l i c y and procedure manual e s s e n t i a l l y centers around h i s or her c l i n i c a l r e s p o n s i b i l i t i e s towards patients, hence neglecting any p o l i t i c a l interventions at a community l e v e l . S ocial change i s not part of the Mental Health Team's mandate. Rather, the focus i s on 'blaming the vict i m ' for inadequate s o c i a l conditions, and the ro l e of g e r i a t r i c s p e c i a l i s t i s no exception to that. A question can also be asked as to why the g e r i a t r i c i a n decided to s p e c i a l i z e i n caring for the e l d e r l y i f , as mentioned e a r l i e r , he does not r e a l l y i d e n t i f y with t h e i r struggle as a disadvantaged people. This can be answered by looking at how s t a f f gains power within the Team. The only means for workers to acquire status and increase t h e i r income i s through s p e c i a l i z a t i o n , not unlike i n the medical profession. Only two s p e c i a l i s t p o s i t i o n e x i s t within a mental health team, that of Family and Ch i l d worker and that of G e r i a t r i c S p e c i a l i s t . Either positions are dependent for t h e i r implementation on a demonstrated need for such service within a given catchment area. The Team investigated here has only one c h i l d and family worker (as opposed to two or 133 three for other teams) for there does not seem to be a 'need' for p s y c h i a t r i c services f o r the families and c h i l d r e n i n i t s catchment area; whereas i t boasts the only g e r i a t r i c s p e c i a l i s t p o s i t i o n for a l l teams because the need for such p o s i t i o n was demonstrated by the g e r i a t r i c i a n who increased the number of r e f e r r a l s of e l d e r l y people through s k i l f u l promotion of h i s services, not unlike p s y c h i a t r i s t s creating new categories of mental disorders to expand t h e i r market (the g e r i a t r i c i a n ' s promotional e f f o r t s were discussed e a r l i e r on i n t h i s chapter). There i s also a b u i l t - i n incentive for the g e r i a t r i c i a n to perpetuate the flow of r e f e r r a l s of e l d e r l y to h i s Team to ensure a demand for h i s services. Although not paid on a fee-for-service basis, i t i s i n h i s i n t e r e s t to continue to show to h i s superiors how needed hi s s p e c i a l i t y i s to avoid h i s dismissal to the lower rank of non-specialist, and hence lose the prestige and increased income he acquired. F i n a l l y , because of the nature of h i s s p e c i a l i z e d services, the g e r i a t r i c i a n has come to serve as a agent control i n various i n s t i t u t i o n a l settings dealing with the e l d e r l y , e.g., nursing homes, which have come to expect such function from him, not unlike p s y c h i a t r i s t s i n prisons or i n the armed forces. Overall then, the g e r i a t r i c i a n ' s actions i n creating and expanding a new market on deviance i n the e l d e r l y should not be viewed as simply those of an i n d i v i d u a l motivated by greed or power. Rather, they are conforming responses to 134 the constraints imposed on him and h i s colleagues by a system which functions within the p s y c h i a t r i c framework, hence s h i f t i n g the r e s p o n s i b i l i t y of inadequate s o c i a l conditions onto indiv i d u a l s rather than on an unjust s o c i a l structure benefiting the dominant s o c i a l c l a s s . 135 CONCLUSION The nature of deviance e s s e n t i a l l y l i e s i n the departure of c e r t a i n types of human behaviour from the normative expectations of a given society at a p a r t i c u l a r time. Deviance i s s o c i a l l y defined and sanctioned as such usually by the dominant members of society i n an attempt to preserve a given socio-economic order from which they benefit. Mental i l l n e s s i s considered a form of deviance because i t involves departure from normal r a t i o n a l behaviour. With the growth of the medical sciences, a number of people started to theorize that the mentally i l l were not responsible for t h e i r behaviour as t h e i r deviance was pr i m a r i l y a disease brought on by an organic impairment of the brain. Mental i l l n e s s became sick behaviour. The pathological d e f i n i t i o n of a c e r t a i n type of deviance into mental i l l n e s s greatly benefitted psychiatry. By gradually increasing the range of deviant behaviour i t could define as i l l n e s s , and by developing s p e c i a l i z e d methods to tr e a t i t , i t started to acquire status and power as a medical s p e c i a l i t y . This resulted i n f i n a n c i a l rewards to p s y c h i a t r i s t s and the health care related industries. However, medicalizing deviance e f f e c t i v e l y i s o l a t e s i t from i t s s o c i a l context and makes i t an i n d i v i d u a l problem. Some authors such as Szasz (1983) go as f a r as saying that mental i l l n e s s i s a myth which the medical profession has 136 created to t r e a t a wide range of problems of l i v i n g stemming from differences i n personal needs, opinions, s o c i a l aspirations, and values between the s o c i a l classes. The e l d e r l y , because of t h e i r lower socio-economic cla s s , tend to experience many problems of l i v i n g due to t h e i r generally poor l i v i n g conditions, i l l n e s s , and d i f f e r i n g needs and values from the younger population. They also are more l i k e l y to be labeled mentally i l l by ps y c h i a t r i c entrepreneurs who are seeking to expand t h e i r market of deviance. This study demonstrates how the process of medicalizing deviance i n the e l d e r l y operates within a community mental health team through the doings of i t s psychogeriatric s p e c i a l i s t . By aggressively promoting mental health services to various professionals and non-professionals working with the el d e r l y , he e f f e c t i v e l y created a network of amateur diagnosticians trained to recognize and r e f e r deviance to the team. Much of the deviance referred to the team, however, has more to do with the problems of l i v i n g outlined by Szasz than with the supposedly organic i l l n e s s e s p s y c h i a t r i s t s t r e a t . Because the g e r i a t r i c s p e c i a l i s t operates under the same constraints as psychiatry for preserving h i s p r i v i l e g e d p o s i t i o n within the team, h i s tendency i s also to continue to medicalize these problems to j u s t i f y t h e i r entry into the Mental Health Team. 137 His approach i s very much related to his i n t e r e s t which does not l i e i n the p o l i t i c a l realm of the e l d e r l y as a disadvantaged people, but rather i n c l i n i c a l realm, with the bio-medical problems t h i s population presents. His aspirations have been at one time to become a p s y c h i a t r i s t . This approach i n a way i s representative of the larger dilemma facing the s o c i a l work profession. H i s t o r i c a l l y , s o c i a l workers have been a c t i v i s t s advocating for improved s o c i a l and economic conditions for the disadvantaged. There was a sense within the profession that the betterment of the poor, the disabled and the d e s t i t u t e were "rooted i n the larger issues of s o c i a l r e l a t i o n of production, s t r u c t u r a l i n e q u a l i t i e s and class p r i v i l e g e , and dominance of p r o f i t s over human needs" (Olson, 1982, p. 225). This sense s t i l l e x i s t s but i t s urgency has been diminished by a gradual s h i f t of the profession towards a c l i n i c a l s p e c i a l i z a t i o n , t r e a t i n g the "sick" i n d i v i d u a l rather than addressing the larger p o l i t i c a l issues of class i n e q u a l i t i e s . This s h i f t i s evidenced by the growth of s o c i a l workers involved i n a wide range of therapeutic enterprises whether i t be of the i n d i v i d u a l , family's, or group type, i n various s e t t i n g such as hosp i t a l s , m i n i s t r i e s ' o f f i c e s , and even schools of s o c i a l work. Interestingly i n the l a t t e r settings, there i s often an i r r e c o n c i l a b l e d i v i s i o n between the teachings rel a t e d to the problems of ind i v i d u a l s versus the teachings of the p o l i t i c a l struggles faced by the s o c i a l groups these i n d i v i d u a l s belong to. Therefore, a student of s o c i a l work 138 has to make a choice between becoming c l i n i c a l s p e c i a l i s t or a community worker, as i f a therapist could not be a community a c t i v i s t or vice versa. Therefore, the tendency of s o c i a l workers (the g e r i a t r i c i a n represented himself as a registered s o c i a l worker) to therapeutize (or medicalize) people's troubles into personal problems i s a move towards blaming the victim. What i s needed i s not more therapy to help the troubled and disadvantaged to conform better to an unjust society. Personal problems have to be relocated into the larger p o l i t i c a l arena were they belong. I s o l a t i n g deviance as i l l n e s s , crime, or d i s a b i l i t y only serves to perpetuate acceptance of the status quo and the i n e v i t a b i l i t y of class inequality. Radical reforms i n the structure of society are needed. These should not be based on the systematic r e q u i s i t e s of capitalism, e.g., increase pensions but r e t a i n mandatory retirement, but rather on working class and community needs. They involve the mobilization of society's surplus of production to s a t i s f y people's needs and requirements, which would r e s u l t i n a more equitable d i s t r i b u t i o n of wealth, income, and power i n society, hence eliminating many of the conditions responsible for deviance. Such reforms, however, w i l l not be coming from the r u l i n g c l a s s and i t s agents who are benefiting from capitalism. Demands for reform w i l l have to be made based on the requirements not just of s p e c i f i c groups such as the e l d e r l y - such demands only serve to perpetuate intergroup 139 r i v a l r i e s - but on the needs of the working class (in which the e l d e r l y are included). The purpose of such demands would be to reveal the incapacity of the actual c a p i t a l i s t order to serve such needs without creating further repressive measures and categories of deviance (the e l d e r l y c l a s s being one of them). According to Olson (1982), what i s needed are "unreproductive demands" i n the form of p o l i c i e s and programs which tend to d e s t a b i l i z e and undermine the basic s o c i a l r e l a t i o n s of capitalism and challenge the underlying p r o f i t maximization premises on which capitalism i s based. The author adds that d e s t a b i l i z i n g demands on the system would prepare the way for a d i a l e c t i c a l struggle to a higher and higher l e v e l where possibly the working class would gain . the power and strength to measure themselves against the power of c a p i t a l and impose t h e i r w i l l on i t . The e l d e r l y as members of the working class can play a key r o l e i n d e s t a b i l i z i n g the e x i s t i n g order of c a p i t a l i s t s as they are possibly the greatest source of "unproductive demands" on the system. There w i l l be a increase i n t h e i r p o l i t i c a l power as the si z e of t h e i r population and t h e i r l e v e l of education increases along with t h e i r l i f e expectancy. Already, the e l d e r l y have come to exercise influence on l o c a l and national government decision-making. I f t h i s trend continues to increase, i t could well be that the e l d e r l y w i l l become a p o l i t i c a l e n t i t y to be reckoned with along with unions and other s o c i a l i s t elements of 140 society. The r i s e of the Gray Panthers i n the U.S.A. since 1970 i s a testimony to the r a d i c a l i z a t i o n of the e l d e r l y i n the past twenty years or so. The Gray Panther Movement has been a prominent c r i t i c of the standards of health care for older people and has been organizing confrontations and marches at meetings of the American Medical Association. This group also organized a convention to explore a l t e r n a t i v e s to compulsory retirement and new approaches to the health care system and p o l i t i c s . F i n a l l y , s o c i a l workers can play a key r o l e i n the mobilization of the working class against the e x i s t i n g s o c i a l order. 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