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Social class and treatment in Burnaby Mental Health Centre Felker, Melvyn B. 1968

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SOCIAL CLASS AND TREATMENT IN BURNABY MENTAL HEALTH CENTRE by MELVYN B. FELKER NICHOLAS D. MANDUCA JEANMETTE E. MATSON EDWARD PRIMAS HANNAH SHNITZLER MARY M. SNELGROVE NANCY R. STIBBARD A Thesis Submitted i n P a r t i a l F u l f i l m e n t of the Requirements f o r the Degree of Master of S o c i a l Work Accepted as conforming to the Standard required f o r the degree of Master of S o c i a l Work School of S o c i a l Work 1968 The U n i v e r s i t y of B r i t i s h Columbia In p re sen t i ng t h i s t he s i s in p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e fo r re ference and Study. I f u r t h e r agree that permiss ion fo r ex ten s i ve copying of t h i s t he s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h.i.'s r e p r e s e n t a t i v e s . It i s understood that copying or p u b l i c a t i o n of t h i s t he s i s f o r f i n a n c i a l gain s h a l l not be a l lowed wi thout my w r i t t e n pe rmi s s i on . Department of The U n i v e r s i t y of B r i t i s h Columbia Vancouver 8, Canada Date ABSTRACT Concern about mental health i s on the increase i n North America. Increased concern necessitated the provision of more treatment f a c i l i -t ies for mental i l l n e s s . For this reason, research i s being conducted in the mental health f i e l d . This study i s the f i r s t undertaken in Canada, i n an attempt to i n -vestigate a possible relationship between social class and mental i l l n e s s . The study focussed on social class and treatment i n a mental health set-ting at the Mental Health Centre, Burnaby, and comparisons were made with studies done i n the United States. Data were made available through the B. C. Department of V i t a l Stat-i s t i c s . These data were collected at the Mental Health Centre, Adult Cl i n i c , Burnaby from Ap r i l 1, 1959 to March 31. 1964. As the data were not collected by the researchers, there are limitations which are dis-cussed i n the study. Of the total number of persons seen at the Adult Cli n i c , 1231 were given treatment and terminated during this five year period. These were the subjects of this study. The findings reveal no significant relationship between social class and the kind of treatment, or, between social class and the length of treatment. However, the findings do indicate that diagnosis i s related to both social class and assignment of a therapist. TABLE OF CONTENTS LIST OF TABLES i LIST OF GRAPHS i i LIST OF TABLES IN APPENDIX i i i Chapter I. INTRODUCTION 2 Purpose History of Mental Health Centre Experimental Variables Review of Literature Hypotheses Assumptions Underlying Hypotheses I I . DESIGN OF THE STUDY . 9 Level of the Design Sampling Design Data Collection Data Analysis Plan Hypothesis I Hypothesis II Hypothesis III Hypothesis TV Description of Population Hypothesis I Hypothesis II Hypothesis III Hypothesis IV IV. DISCUSSION AND CONCLUSIONS 25 III . FINDINGS 15 APPENDIX.... BIBLIOGRAPHY 30 37 i LIST OF TABLES Table Page I Percentage Table o f income d i s t r i b u t i o n i n four diagnostic categories 16 I I Percentage table of occupation d i s t r i b u t i o n i n four diag-n o s t i c categories 17 I I I Percentage table f o r hours of psychotherapy d i s t r i b u t i o n i n four income l e v e l s 18 IV Percentage table of patients i n four income l e v e l s and assignment of th e r a p i s t f o r a l l diagnostic categories 19 V Percentage table of schizophrenic patients i n four income l e v e l s and assignment of th e r a p i s t 20 VI Percentage table of depressive r e a c t i o n patients i n four income l e v e l s and assignment of t h e r a p i s t 20 VII Percentage table of patients i n f i v e education l e v e l s and assignment of t h e r a p i s t f o r a l l diagnostic categories 21 VIII Percentage table of schizophrenic psychotic patients i n f i v e education l e v e l s and assignment of therapist 22 IX Percentage table of four diagnostic categories and assign-ment to therapist f o r a l l patients f o r whom income was recorded 23 i i LIST OF GRAPHS Graph Page Group Bar Graph: Percentage d i s t r i b u t i o n of t o t a l population receiving psychotherapy or electrotherapy treatment 24 i i i i LIST OF TABLES IN APPENDIX Table Page 1 Percentage table of education distribution in four diagnostic categories . . 30 2 Percentage table of schizophrenic psychotics in four income levels and hours of psychotherapy 31 3 Percentage table of phobic and anxiety reaction patients in four income levels and hours of psychotherapy 32 4 Percentage table of depressive reaction patients in four income levels and hours of psychotherapy 33 5 Percentage table of personality t r a i t disturbance patients in four income levels and hours of psychotherapy 34 6 Percentage table of phobic and anxiety reaction patients in four income levels and assignment of therapist 35 7 Percentage table of personality t r a i t disturbance patients in four income levels and assignment of therapist 35 8 Percentage table of patients in five occupation categories and assignment of therapist 36 9 Percentage table of phobic and anxiety reaction patients in five education levels and assignment of therapist . . . 36 1 ACKNOWLEDGEMENTS We wish to express our appreciation to those who have assisted us in the preparation and development of this study. Mrs. Tanabe, advisor to this thesis project, has been most patient and helpful throughout the duration of the project. Her guidance has been greatly appreciated. We extend our thanks to staff members at the Mental Health Centre, Burnaby. Their informal discussions, their professional experience and co-operation with technical information has greatly assisted our under-standing and interpretation of the study findings. 2 CHAPTER I INTRODUCTION Purpose The purpose of t h i s study i s to determine i f there i s any r e l a t i o n -ship between s o c i a l class and treatment i n the Mental Health Centre, Bur-naby. We have set up four hypotheses to discover i f a r e l a t i o n s h i p e x i s t s : (1) i s there a r e l a t i o n s h i p between s o c i a l c l a s s and the type of mental i l l n e s s which a patient has? (2) i s the patient's s o c i a l class r e l a t e d to the length of time he w i l l remain i n psychotherapy? (3) i s the p r i n c i p a l t h e r a p i s t assigned according to the s o c i a l c l a s s of the patient? and i s the patient with a higher class status more l i k e l y to receive a v e r b a l form of therapy than a patient with a lower cl a s s status? I t was hoped that the data a v a i l a b l e to us on the Adult C l i n i c , Mental Health Centre, Burnaby, from 1959-1964, through the B r i t i s h Columbia De-partment of V i t a l S t a t i s t i c s would confirm or refute our hypotheses. I t should be noted that t h i s data was not c o l l e c t e d with any s p e c i f i c r e -search problem i n mind. Thus, there are some areas where information i s l a c k i n g f o r our p a r t i c u l a r research study. We be l i e v e , however, that t h i s study has value to anyone conducting f u r t h e r research studies about mental health c l i n i c s i n Canada. I t could be used f o r the purpose of comparison with other studies i n t h i s f i e l d , as w e l l as to in d i c a t e areas where information should be c o l l e c t e d i f a v a l i d measure of s o c i a l c l a s s i s to be obtained. From the d i f f i c u l t i e s 3 experienced in this study i t might also be possible to suggest changes in the statistical forms used by the British Columbia Department of Vital Stat-istics to obtain information on social class and mental illness. History of Mental Health Centre, Burnaby The Burnaby Mental Health Centre was established in 1957 for the pur-pose of treating people on an out-patient basis. It was necessary that referrals made to the clinic come from a physician practicing within the province. However, various agencies and people in the community such as Social Welfare Departments, Community Health Services, Penal Institutions, Police, etc., could initiate the referral by bringing the individual (potential patient) to the attention of a physician. The Mental Health Centre did not charge a fee and, therefore, acceptance for treatment at the clinic did not depend on the potential patient's income, but rather on a diagnostic assessment by the intake team. Experimental Variables Mental Illness is a dependent variable and for the purpose of this study we are assuming that individuals referred to the clinic are in need of psychiatric treatment, in that they have a mental disturbance with either an emotional or organic base. Treatment is an independent variable which we have divided into the further variables of type of treatment and length of treatment. The types of treatment provided at the Burnaby Mental Health Centre can be divided into two main categories: 1. Verbal therapies which include: (a) individual psychotherapy (b) group psychotherapy (c) day hospital or milieu therapy k 2. Non-Verbal therapies which make use of some form of physical and/ or chemical intervention: (a) electrotherapy (b) somnolent insulin We have used two dimensions to measure length of treatment. These are: 1. Number of hours of psychotherapy 2. Length of contact with the cl inic. Although we cannot equate length of treatment with success in treat-ment, we can argue that continuation is a necessary condition for the successful use of treatment, for, "knowledge about the correlates of continuance-discontinuance contributes directly to an understanding of the determinants of success and failure in treatment". (10, p.21) Principal Therapist is the third dependent variable. This is the therapist; i . e . , psychiatrist, psychologist, social worker or nurse, to whom any case is officially assigned. The principal therapist is the person who gives most treatment to the patient, often in consultation with other team members. Social Glass is the independent variable we have used. There are grades and distinctions of social class between people with different occupations, levels of education, and levels of income. (16, p.l60) Blishen has combined income and education with occupation in a scale to successfully measure social class. (16, p.l60) We did not, however, have sufficient information to use Blishen's scale and have, therefore, indicated social class by using each of these separately. We have used four categories of income (high, average, low and sub-sistence); five categories of occupation (professional and managerial, clerical and sales, skilled, semi-skilled and unskilled); five categories 5 of education (less than seven years, seven to eleven years, high school graduate, technical training, university or equivalent professional training). Review of Relevant Literature In examining the literature on the relationship between social class and treatment of mental illness, we found varying conclusions depending on the population studied, the types of treatment administered, and the type of treatment agency studied. One of the major studies (5) found that the lower the class, the greater the proportion of patients treated in public agencies, and, that psychotherapeutic methods (particularly insight therapy) are applied in disproportionately high degrees to higher status neurotic patients. Organic therapies tend to be applied more often to neurotics in middle and lower middle classes. Among neurotic patients, the higher the class, the longer the patients are in treatment. We might expect our findings to differ in these areas, as the Hollingshead and Redlieh study included state, veteran and private hospitals, private practicioners, as well as out-patient clinics. Myers and Shaffer (13, pp. 307-310), however, studied an out-patient clinic where only psychotherapy W a s given and income of patients was under five thousand dollars per year. They found the following: that the higher a person's social class, the more likely he would be chosen for treatment; that he would be treated by highly trained personnel; that he would be treated intensively over a long period of time. E r i l l and Storrow (2 p. 68) also found a significant relationship between social class and whether a patient was accepted for treatment. 6 They discovered no relationship between social class and training and/or experience of the therapist. Imber, Nash, and Stone (6 pp. 281-28*0 found that the lower class remained in treatment for a shorter time period than the middle class and that the lower class was less likely to return after in i t ia l screening. McMahan (9 p. 283) studied the working class psychiatric patient from a cl inical point of view and also found that for the lower class, psy-chiatric care is more unavailable than for other classes and that therapy for the poor is usually of a shorter duration than for the middle classes. A study by Pasamanick, et a l . , (Ik p. 39) shows that: the prevalence of psychoses fal ls as income increases; that the prevalence of treated neurosis is highest in the lowest income group and falls progressively, then, rises again in the highest income group; that, the prevalence of psychophysical, autonomic and visceral disorders increase directly with income. The f irst finding of Pasamanick agrees with the findings of Hollingshead and P.edlich. We have used some of the above findings as a basis for our hypotheses relating to social class and treatment at Burnaby Mental Health Centre. Hypothesis I The type of mental illness which a person manifests is associated with his social class. (By type of mental illness, we mean the psychia-tr ist 's diagnosis made when the patient f irst presents himself to the c l inic) . Sub-hypotheses A. The type of mental illness a person manifests is associated with his educational level. B. The type of mental illness a person manifests is associated with his income level. C. The type of mental illness a person manifests i s associated with his occupational level. Hypothesis I I The higher the patient1s social class, the longer he wi l l remain in treatment. (Length of treatment is measured by number of hours of psycho-therapy and the length of contact with the cl inic.) Sub-hypotheses A. The higher the patient's educational level, the longer he wil l remain in treatment. B. The higher the patient's income level, the longer he wi l l remain in treatment. C. The higher the patient's occupational level, the longer he wil l remain in treatment. Kypothesis m The patients with higher social class wi l l be assigned to a princi-pal therapist with higher status and longer training than patients of lower social class. (The highest status is assigned to the psychiatrist, while a l l others such as social workers, psychologists, and nurses have been assigned the same status in this study; i . e . , below that of the psychiatrist.) Sub-hypotheses A. Patients with higher educational levels wi l l be assigned a principal therapist of higher status. B. Patients with higher income levels wil l be assigned a principal therapist of higher status. C. Patients with higher occupational levels wi l l be assigned a principal therapist of higher status. Hypothesis IV The higher the patient's social class, the more likely he is to receive a verbal form of therapy, while those in lower social classes wil l be more likely to receive a non-verbal form. Sub-hypotheses A. The higher the patient's educational level, the more likely he is to receive a verbal form of therapy. B. The higher the patient's income level, the more likely he is to receive a verbal form of therapy. C. The higher the patient's occupational level, the more likely he is to receive a verbal form of therapy. Assumptions Underlying the Above Hypotheses 1. We assume that there is a social class structure in Canadian society. For the purposes of this study, we are measuring this by the three variables of occupation, education and income. 2. We assume, that since the Mental Health Centre, Burnaby, is available to a l l social classes, our population from 1959 to 1964 should be representative of a wide range of social classes. 3. We assume that individuals living in a given social class exper-ience problems of living that are expressed in psychological reactions and disorders differing in quantity and quality from those expressed by persons in other classes. 9 CHAPTER II DESIGN OF THE STUDY Level of the Design The present study examines the relationship between both past and present variables which were taken at a single point in time, and in-cluded retrospective data. Therefore, the design used in this study is an Ex Post Facto Survey. The requirements for causal explanations in this type of design are: (a) Controlling the time order of the variables. Social Class was established before the determination of treatment. In this sense, the time order of variables was controlled. We are not concerned with future variables. (b) Ruling out alternative explanations. In order to achieve this, limited control is attained in this type of design through the use of matching techniques. In the present study, there is a large sample which allowed us to control for diagnosis to test whether this is a significant variable rather than social class factors. Sampling Design In this study, the total number of subjects was 1,231. These patients were at least sixteen years of age and had their treatment terminated in the Adult Clinic at Burnaby Mental Health Centre between April 1, 1959 and March 31. 1964. Excluded from the study were 1,681 people who were assessed, but not engaged in treatment. Data collected before April 1, 1959 were not used for this study because uniform practices for data col-lection were then in process. Data collected after March, 1964 were not used because Burnaby Mental Health Centre changed the data collection instrument. Hence, the data used in this study are restricted to the stated time. Data Collection Data used were made available through the British Columbia Department of Vital Statistics. These data had been collected by the provincial Mental Health Centre in Burnaby. Data were collected on the basis of standard information obtained on each applicant appearing at the c l inic . This in-formation was used as a f i le face sheet as well as for the purposes of government statistics. At the time of intake, basic information, such as residence, education, occupation and income was recorded by the receptionist. Reliability of the data is increased through having one person collect the information according to standard procedures. However, occupation recorded was that of the patient seen and not that of the head of the household. In the case of employed women who were married and living with their husbands, and those patients residing with their parents, the occupation recorded may not reflect their social class. In fact, 40$ of the women were employed. This creates distortion inherent in the data collection. The same distortion is inherent in the data on education, which was recorded about the patient seen, and not about the head of the household. A l l the women were included in this analysis, as opposed to 40$ in the variable, occupation. "Validity of education as a measure of social class is thus impaired to a greater degree than in the use of occupation. The highest validity is in the use of income as a measure of social class because the income recorded was that of the total family earnings. The least valid measure of social class is education. Diagnosis was recorded by a psychiatrist or principal therapist following an assessment period with the patient. There was, as well, a final diagnosis recorded at the end of treatment, but in this study we are using the in i t ia l diagnosis. Diagnoses are reliable because the therapists were uniformly trained in the use of diagnostic categories based on the American Psychiatric Association classification. (1) Upon termination of the case, the principal therapist recorded the data of termination, and the length and type of treatment. Data Analysis Plan Data were analyzed through the use of a computer program designed for multivariate analysis. The independent variable in a l l hypotheses is social class which is inferred from the measurements of education, occupation and income. Education was recorded as the .highest school grade completed and then assigned to one of five categories for purposes of our study. These categories are less than grade seven, grade seven to eleven, high school graduation, technical training and university. Occupation was grouped into nine categories which are professional and managerial, clerical and sales, skilled labor, semi-skilled labor, and unskilled labor. Housewives and students were excluded in a l l ana-lyses involving occupation, as they do not give a measure of social class. Total family income was assessed in relation to the number in the family and recorded systematically as high, average, low or subsistence. 12 It was adjusted for cost of living changes within the five-year period. The distortion inherent in the data collection of education and occupation has already been discussed above. Because of the nature of the recording of these factors, i t was not-possible to derive a composite measure of social class. Hence, this variable wil l be inferred from separ-ate analysis of each of the three measures. Hypothesis I: The Relationship Between Social Class and Diagnosis The dependent variable is the type of mental illness. Diagnoses re-corded were based on the American Psychiatric Association classification. Diagnoses were grouped into four categories of schizophrenic psychoses, phobic and anxiety reactions and personality trait disturbance. These corresponded to major headings of the American Psychiatric, Association classification. Seventy-two percent of the patients are diagnosed within these categories. Hypothesis II: Relationship Between Social Class and Length of  Treatment Two measurements employed for the dependent variable of length of treatment are: length of time Under care recorded in months and grouped into categories of under one month, one to three months, four to six months, seven to nine months, ten to twelve months and thirteen or more months; and number of hours of psychotherapy grouped into categories of one to five hours, six to ten hours, eleven to fifteen hours, sixteen to twenty hours, twenty-one to twenty-five hours, and twenty-six or more hours. These two measurements were analyzed separately. Termination date was determined by the date on which the case was presented to an interdisciplinary conference, rather than by the time at 13 which dictation on the f i le was completed. Thus, any source of error would be in the delay between the final interview and the conference date. Information from the clinic staff indicates that this delay was minimal, and hence, the validity of this measurement is not greatly impaired. To increase the validity of the conclusions to be drawn, the second measurement of number of hours of psychotherapy was used. Other treatment methods offered by the clinic were group therapy, electrotherapy,' and somnolent insulin (sleep therapy). However, only hours of psychotherapy was used in the hypothesis because this includes the largest proportion of patients. Hypothesis III: Relationship Between Social Class and Status of  the Therapist The dependent variable of status of therapist is operationally defined by two categories: that of psychiatrist and social worker. Other pro-fessions, namely, psychologists, nurses, occupational and physiotherapists were excluded because less than 5$ of the population were treated by them. Psychiatrists were assigned the higher status because of having greater specialization and length of training. Hypothesis IV: Relationship Between Social Class and Type of Treat- ment The dependent variable of treatment is operationally defined by two categories: psychotherapy which is a verbal therapy; electrotherapy which is a non-verbal type of therapy. Somnolent insulin and group therapy were not used because too few people received these treatments to permit analysis. Because of the nature of the computer programme, i t was necessary to analyze the data according to the distribution of social class for each of the two types of treatment. Diagnosis was not used for electrotherapy analysis because few patients received this type of treatment. CHAPTER III FINDINGS Description of Population The majority of the c l i n i c population comes from the middle and lower status groups. Sixty-two percent of the patients are i n the average i n -come group, while only 4$ of the patients are of the high income category. Sixty-four percent have less than Grade 12 education. Considering occupa-tion, only 2?$ are included in the managerial, professional and skilled occupations. From this, we may conclude that the c l i n i c population i s biased toward the middle and low social class groups. Hypothesis I A percentage distribution of the total patient population of 1,231 reveals that 73$ of the patients f a l l into four categories of mental i l l n e s s . These are: (1) Schizophrenic psychosis - 24$; (2) Phobic and Anxiety Reactions - 13$; (3) Depressive Reactions - 25$; and (4) Personality Trait Disturbance - 11$. Our findings indicate that there i s a definite relationship between diagnosis and two of the variables which we chose to determine social class, that i s , income and occupation, at a level of significance of .01 (See Tables I and I I ) . However, there i s no relationship between education and diagnosis. The level of significance here i s .30 (See Appendix, Table 1). 16 Looking at the horizontal percentages for income compared to diagnosis we find that 46$ of the patients with a subsistence level of income have schizophrenic psychosis, while only 16$ of the patients who have a high income level f a l l into this same diagnostic category (See Table I ) . TABLE I PERCENTAGE TABLE OF INCOME DISTRIBUTION IN FOUR DIAGNOSTIC CATEGORIES Income Schi zophrenic Psychoses Phobic and Anxiety Reactions Depressive Reactions Personality Trait Disturbance n High 16.67 16.67 56.67 10.00 30 Average 30.91 19.18 36.13 13.78 537 Low 32.21 15.38 33.17 14.23 208 Subsis-tence 46.32 •t 15.79 20.00 17.89 95 Total Percent-age 32.41 17.82 34.37 15.40 870 x2= 24.293 p .01 df = 9 Looking at the horizontal percentages for occupation compared to diagnosis we find that 50$ of the patients who are unskilled have schizo-phrenic psychosis while only 36$ of the patients in a professional occupa-tion f a l l into this same diagnostic category (See Table I I ) . 17 TABLE II PERCENTAGE TABLE OF OCCUPATION DISTRIBUTION IN FOUR DIAGNOSTIC CATEGORIES Occupa-tion Schizophrenic Psychoses Phobic and Anxiety Reactions Depressive Reactions Personality Trait Disturbance n Profes-sional 36.21 24.1*4- 36.21 3.^ 5 58 Clerical & Sales 36.91 1^ .77 30.20 18.12 149 Skilled 25.81 2 9 . 0 3 29 .03 16.13 6 2 Semi-skilled 32.73 18.18 2 9 . 0 9 20.00 55 Unskilled 50.46 8 . 2 6 23.85 17.^3 1 0 9 Total 38 . 11 16.86 2 9 . 1 0 15.9^ 433 28.802 p .01 df = 12 From these two horizontal percentage tables, we can state that the lower the income and the occupational status of the patient, the higher the rate of psychosis. In the table showing income and diagnosis, the high income population is 3 0 . (See Table I). Seventy-three percent of these patients f a l l into the two combined neurotic categories, phobic and anxiety reactions and depressive reactions. Only 3 6 $ of the 9 5 people at the subsistence level of income, are included in these same two categories. Of the professional and managerial population, which is 5 8 . in the table showing occupation and diagnosis (See Table II), 6 0 $ of these patients f a l l into the two combined neurotic categories, while only 3 2 $ , of the unskilled population, which is 1 0 9 , are included in these same two categories. I t should be noted that the majority of neurotic patients f a l l into the depressive reaction category. From these horizontal percentages, i t would appear that those patients from the high income level and from the professional and managerial occu-pations tend to be neurotic, whereas, those patients from the subsistence lev e l of income and unskilled tend to be psychotic. Hypothesis I I . Our findings reveal that there i s no significant relationship between the patient's social class and the length of time he w i l l remain in treat-ment. For example, in analyzing the relationship between number of hours of psychotherapy and levels of income, the level of significance achieved was less than .50 (See Table I I I ) . TABLE III PERCENTAGE TABLE FOR HOURS OF PSYCHOTHERAPY DISTRIBUTION IN FOUR INCOME LEVELS Income 1-5 Hrs 6-10 Hrs 11-15 Hrs 16-20 Hrs 21-25 Hrs 25+ Hrs n High 50.00 28.57 2.38 7.14 0.00 11.90 42 Aver-age 45.74 20.57 8.93 6.04 5-55 13.13 739 Low 49.13 18.47 10.10 4.88 4.53 12.89 287 Subsis-tence 37.19 25.62 8.26 8.26 7.44 13.22 121 45.89 20.86 8.92 6.06 5.30 13.04 1189 x 2 = 14.114 p .50 df = 15 It i s interesting to note that the length of treatment measured by hours of psychotherapy did not vary significantly when controlled for 19 diagnosis. Our horizontal percentage tables indicate a higher proportion of schizophrenic patients receiving one to.ten hours of psychotherapy than those patients diagnosed as neurotic or personality trait disturbance (See Appendix, ,,.Tables 2, 3» 4 and 5). Similar results were obtained with a l l three variables of social class. Hypothesis III TABLE IV PERCENTAGE TABLE OF PATIENTS IN FOUR INCOME LEVELS AND ASSIGN-MENT OF THERAPIST FOR ALL DIAGNOSTIC CATEGORIES Income Psychiatrist Social Worker n High 80.49 19.51 41 Average 70.51 29.49 712 Low 63.84 36.16 271 Subsis-tence 47.^ 52.54 118 Total 66.90 33-10 1142 x 2 = 28.890 p .001 df = 3 The analysis of the total population seemed to show a significant relationship between income and assignment of therapist. (See Table IV) However, further analysis indicated that diagnosis xvas a more signifi-cant variable than income. 20 TABLE V PERCENTAGE TABLE OF SCHIZOPHRENIC PATIENTS IN FOUR INCOME LEVELS AND ASSIGNMENT OF THERAPIST Income Psychiatrist Social Worker n High 100.00 0.00 5 Average 76.25 23.75 160 Low 69.84 30.16 63 Subsis-tence 59.09 40.91 44 Total 72.43 27.57 272 x 2 = 7.204 p .10 df = 3 TABLE VI PERCENTAGE TABLE OF DEPRESSIVE REACTION PATIENTS IN FOUR INCOME • LEVELS AND ASSIGNMENT OF THERAPIST Income Psychiatrist Social Worker n High 94.12 5.88 17 Average 64.06 30.94 181 Low 67.69 32.31 65 Subsis-tence 50.00 50.00 18 Total 72.20 27.80 277 x 2 = 8.109 p .05 df = 3 From Tables V and VI, i t may be seen that the relationship between income and therapist noted for the total population is largely accounted for by the psychotic and depressive reaction diagnostic groups, that i s , both diagnostic groups tend to be seen by a psychiatrist. No relationship was found in the phobic and anxiety reactions, and personality trait dis-turbance groups. Levels of significance were .30 and .20 respectively. (See Appendix, Tables 6 and 7) There is no relationship between occupation and therapist as level of significance was .20. This finding held for a l l diagnostic categories. (See Appendix Table 8) TABLE VII PERCENTAGE TABLE OF PATIENTS IN FIVE EDUCATION LEVELS AND ASSIGNMENT OF THERAPIST FOR ALL DIAGNOSTIC CATEGORIES Education Psychiatrist Social Worker n Less Grade 7 68.52 31.48 54 7-11 Years 64.12 35.88 680 High School 69.23 30.77 260 Technical 50.00 50.00 36 University 78.57 \ 21.43 ' 126 Total 66.61 33.39 1156 x 2 = 15.361 p .01 df = 4 As with income, there appeared to be a significant relationship between level of education and assignment of therapist. (See Table VII) However, this is largely accounted for in that 9^ $ of patients with schizophrenic psychosis and a university education are treated by a psychiatrist. (See Table VIII) 22 TABLE VTLT PERCENTAGE TABLE OF SCHIZOPHRENIC PSYCHOTIC PATIENTS IN FIVE EDUCATION LEVELS AND ASSIGNMENT OF THERAPIST Education Psychiatrist Social Worker n Less Grade 7 58.82 41.18 17 7-11 Years 71.43 28.57 161 High School 71.93 28.07 57 Technical 40.00 60.00 10 University 93.75 6.25 32 Total 72.20 27.80 277 x 2 = 14.136 p .01 df = 4 Analysis of other diagnostic categories revealed no relationships between education arid therapist, (depressive reaction, p = .70, phobic and anxiety reactions p = .70, and personality trait disturbance p = .80.) (See Appendix, Table 9) Therefore,, diagnosis appears to be more influential than education or income in the assignment of therapist. In an attempt to account for this, we compared percentages in each diagnostic category with the assignment of therapist. This was done separately for patients for whom income, occupation and education were recorded* (See Table IX) In a l l three cases we found a pattern that indicated schizophrenic psychotics and depressive reactions were more l ikely to be assigned to a psychiatrist than the other two diagnostic categories. 23 TABLE IX PERCENTAGE TABLE OF FOUR DIAGNOSTIC CATEGORIES AND ASSIGNMENT TO THERAPIST FOR ALL PATIENTS FOR WHOM INCOME WAS RECORDED Diagnosis Psychiatrist Social Worker Schizophrenic Psychosis 72.43 27.57 Phobic & Anxiety Reaction 60.81 39.19 Depressive Reaction 69.04 30.96 Personality Trait Disturbance 55.81 44.19 Rypothesis IV From an examination of the population receiving verbal therapy in the form of psychotherapy, the population receiving non-verbal electro-therapy treatment, no relationships or trends were seen between the measures of social class and the forms of treatment. For purposes of comparison, the percentage distribution of the income and occupation measures to.the two treatment populations is taken. The total population receiving electrotherapy treatment is 8 9 i while the population receiving psychotherapy is 1134. (See Graph 1) 24 GRAPH I PERCENTAGE DISTRIBUTION OF TOTAL POPULATION RECEIVING PSYCHO-THERAPY OR ELECTROTHERAPY TREATMENT Percent 10 20 30 High Income Low Income Subsistence Income Managerial and Pr o f e s s i o n a l Occupations S k i l l e d Occupations Semi-Skilled U n s k i l l e d Occupations £ 2 3 2 2 H II H H K lr: n mi MM ii M Mint K HTHTinonQ I X X X X X X X X X H M hAHhXJ x x x x x x x x x X x X XXXI H h H ii It HH IiIIHHIIHIIHUH h 10 X H 2 X H I 2 2 1 x y x x x x x x x m x x x x x x x x x x x x x T n n a .'•TV«*TtI«*Tt!*»:i»I«tI«»I*IMI«It Legend: Psychotherapy XXXXX Electrotherapy 00000 GROUP BAR GRAPH 25 CHAPTER IV DISCUSSION AND CONCLUSIONS In comparing our findings to those of Hollingshead and Redlich (5) i we found a relationship (p=.01) between diagnosis and two measures of social class; i . e . , income and occupation. Forty-six percent of the patients with a subsistence level of income have schizophrenic psychosis, while only 16$ with a high income f a l l into the same diagnostic category. \ Fifty percent of the unskilled patients are diagnosed as schizophrenic, while only 36$ of the patients in the professional and managerial category are diagnosed as schizophrenic. Hence, we can conclude from our study that the lower the income and the lower the occupational status, the higher is the incidence of schizo-phrenic psychosis. This agrees with findings in studies done by Hollings-head and Redlich (5)» and Pasamanick, et a l . (14) . If Hollingshead and Redlich's findings of an inverse relationship between social class and prevalence of psychoses in the general population is correct, this pattern is to be expected in our study. The greatest percentage of patients in the high income level are diagnosed as neurotics. For example, 56.67$ of the high income category are diagnosed as depressive. From this, we can conclude that the higher the income the greater the incidence of neurosis. Like Myers and Schaffer (13). B r i l l and Storrow (2), we found no relationship between measures of social class and length of time in treatment. We found, howeverj that there is a higher proportion of schizophrenic patients terminating after one to ten hours of treatment than persons diagnosed as neurotic or personality trait disturbance. For example, 7^$ of the schizophrenic psychoses terminate after one to ten hours of treatment, while 58$ of phobic and anxiety reactions, 68$ of depressive reactions, and 59$ of personality trait disturbances ter-minate within the same number of hours of treatment. One possible reason for this finding might be that psychotics were given a t r i a l period of treatment, after which, i f unsuccessful, patients were referred to other resources such as the provincial mental hospital. Another reason might be the fact that by their very nature, psychotics . are the type of people who are unable to keep regular appointments, and are, therefore, prevented from continuing treatment. Our i n i t i a l findings, before controlling for diagnosis, showed that the higher the patient's social class, the more likely he wi l l be treated by more highly trained personnel. This agrees with the findings of Myers and Schaffer (13). However, our control for Hypothesis III showed that diagnosis is a more important factor in determining the assignment of patients to therapists than is social class. The findings indicated that schizophrenic psychoses and depressive reactions were more likely to be assigned to a psychiatrist than the other two diagnostic categories. Furthermore, as discussed above, schizo-phrenic psychoses are more prevalent in lower classes and depressive reactions are more prevalent in the higher classes. Thus, the two diagnosis categories more l ikely to be treated by a psychiatrist cut across the social classes and, therefore, we can conclude that diagnosis is a more important factor than social class in determining assignment to therapist. This would indicate a need for a future study, using the relationship between diagnosis and therapist, and controlling for other variables. We found no relationship between social class and type of treatment; i . e . , verbal (psychotherapy) and non-verbal (electrotherapy). Our find-ings do not agree with Hollingshead and Redlich (5). who found that psycho-therapeutic methods are applied in disproportionately high degrees to higher status neurotic patients, while organic therapies tend to be applied to those neurotics in the middle and lower middle classes. Our total electrotherapy population, however, was only 89. compared to a population of 1,134 receiving psychotherapy. With such a small electro-therapy population, our results may have been skewed. Of the small number of patients receiving this form of treatment,we can see by Graph I (p.24) that for the highest income and occupational groups, there is a greater percentage of patients receiving electrotherapy than psychotherapy. This may possibly be accounted for by private psychiatrists referring their patients to Burnaby Mental Health Centre specifically for electro-therapy treatments. We also speculate that assignment to a psychiatrist may be due ;fco the fact that certain types of mental illness require medication. Further, we speculate that there may be an unwritten rule in the clinic whereby patients with a certain mental illness are assigned to a psychiatrist rather than to a social worker. Future studies might indicate a shift toward non-verbal therapies, such as E . C . T . , as current research seems to point out that there are organic factors to consider in treating mental illness. In general, from the income measure of social class, our findings would appear to agree with Hollingshead and Redlich (5) who found that the lower the class, the greater the proportion of patients treated in public agencies. In our study, the average, low and subsistence income groups composed 96fo of the total population. According to our study, as indicated in Hypothesis II and IV, there is no significant relationship between social class and treatment, or, between diagnosis and treatment. Therefore, there must be other intervening variables that we have not considered, which affect treatment. However, we cannot draw any such conclusions about the relationship between social class and the treatment of mental illness in the general population, or, in other psychiatric treatment faci l i t ies , as this study was restricted to an outpatient mental health cl inic . Hopefully, future studies wil l be done in this field which wil l lead to a more generalized view of mental illness in Canada. In looking at these results, one must keep in mind the following distortions inherent in our data collection instrument: (i) we do not always have a measure of the education or occupation of the head of the household, but rather that of his working wife and/or working son or daughter; and, ( i i ) unlike Hollingshead and Redlich, we were unable to obtain data that would give us a composite index of social class ( 4 ) . Ideally, i f this kind of research is to be done again, information should be recorded on the head of the household. Conclusion Our study indicates that diagnosis is related to social class, that is , depressive reactions are associated with the higher class, and schizo-phrenic psychoses are associated with the lower classes. Furthermore, the patients in these two diagnostic categories tend to be assigned to the psychiatrist rather than to a social worker for treatment. We conclude, then, that diagnosis is more important in the assignment of a therapist than is social class. TABLE 1 PERCENTAGE TABLE OF EDUCATION DISTRIBUTION IN FOUR DIAGNOSTIC CATEGORIES Phobic & Anxiety Depressive Psychoses Reactions Reactions P e r s o n a l i t y T r a i t Disturbance n Less Grade 7 37.50 7-11 Years 32.68 High School 29.27 Technical 32.26 U n i v e r s i t y 32.93 14.58 16.93 20.00 19.35 21.84 29.17 33.07 35.61 35-^ 36.78 18.75 17.32 15.12 12.90 3.45 -46 508 205 31 87 T o t a l 32.65 18.09 33.90 15.36 879 x 2 = 14.264 P .30 df = 12 TABLE 2 PERCENTAGE TABLE OF SCHIZOPHRENIC PSYCHOTICS IN FOUR INCOME LEVELS AND HOURS OF PSYCHOTHERAPY 1-5 Hrs. 6-10 Hrs. 11-15 Hrs. 16-20 Hrs. 21-25 Hrs. 26+ Hrs High 80.00 20.00 .00 .00 .00 .00 Average 58.18 17.58 6.67 6.67 4.24 6.67 Low 50.75 20.90 5.97 2.99 7.46 11.94 Subsistence . ^ 5-75 25.00 6.82 k.55 9.09 9-09 54.80 19.57 6.41 5.34 5.69 8.19 x 2 = 9.41 p .80 df = 15 TABLE 3 PERCENTAGE TABLE OF PHOBIC AND ANXIETY REACTION PATIENTS IN FOUR INCOME LEVELS AND HOURS OF PSYCHOTHERAPY 1-5 Hrs. 6-10 Hrs. 11-15 Hrs. 16-20 Hrs. 21-25 Hrs. 26+ Hrs. High .00 40.00 .00 .00 .00 60.00 Average 34.31 22.55 12.75 6.86 2.94 20.59 Low 34.38 25.00 12.50 12.50 .00 15.63 Subsistence 40.00 26.67 6.67 6.67 6.67 13.33 33.77 24.03 11.69 7-79 2.60 20.13 x 2 .= 11.603 P .70 df = 15 TABLE 4 PERCENTAGE TABLE OF DEPRESSIVE REACTION PATIENTS IN FOUR INCOME LEVELS AND HOURS OF PSYCHOTHERAPY. 1-5 Hrs. 6-10 Hrs. 11-15 Hrs. 16-20 Hrs. 21-25 Hrs. 26+ ] High 52.94 29.41 .00 11.76 .00 5.88 Average 40.93 25.39 7.25 5.70 4.66 16.06 Low- 52.17 17.39 8.70 4.35 5.80 11.59 Subsistence 31.58 31.58 10.53 .00 15.79 10.53 43.62 24.16 7.38 5.37 5.37 14.09 x 2 = 15.^5 P .30 df = 15 TABLE 5 PERCENTAGE TABLE OF PERSONALITY TRAIT DISTURBANCE PATIENTS IN FOUR INCOME LEVELS AND HOURS OF PSYCHOTHERAPY 1-5 Hrs. 6-10 Hrs. 11-15 Hrs. 16-20 Hrs. 21-25 Hrs. 26+ Hrs. High 66.67 .00 33.33 .00 .00 .00 Average 43.24 14.86 14.86 4.05 9.46 13.51 Low 41.03 20.51 17.95 .00 2.56 17.95 Subsistence 29.41 29.41 17.65 11.76 5.88 5.88 41.35 18.05 16.54 3.76 6.77 13.53 x 2 = 12.348 P .70 df = 15 35 TABLE 6 PERCENTAGE TABLE OF PHOBIC AND ANXIETY REACTION PATIENTS IN FOUR INCOME LEVELS AND ASSIGNMENT OF THERAPIST Income P s y c h i a t r i s t S o c i a l Worker n High 60.00 40.00 5 Average 66.00 34.00 100 Low 50.00 50.00 28 Subsistence 53.33 15 T o t a l 60.81 39.19 148 x 2 = 3.764 p 30 df = 3 TABLE 7 PERCENTAGE TABLE OF PERSONALITY TRAIT DISTURBANCE PATIENTS IN FOUR INCOME LEVELS AND ASSIGNMENT OF THERAPIST Income P s y c h i a t r i s t S o c i a l Worker n High 66.67 33.33 3 Average 63.89 36.11 72 Low 44.74 55.26 28 Subsistence 43.75 56.25 16 T o t a l 55.81 44.19 129 x 2 = 4.882 p .20 df = 3 TABLE 8 PERCENTAGE TABLE OF PATIENTS IN FIVE OCCUPATION CATEGORIES AND ASSIGNMENT OF THERAPIST Occupation P s y c h i a t r i s t S o c i a l Worker n Pr o f e s s i o n a l 69.51 30.49 82 C l e r i c a l & 67.15 32.85 207 Sales S k i l l e d 73.68 26.32 76 Semi- 54.55 45.45 66 S k i l l e d U n s k i l l e d 63.33 36.67 150 T o t a l 65.92 34.08 581 x 2 = 6.687 P .20 df = 4 TABLE 9 PERCENTAGE TABLE OF PHOBIC AND ANXIETY REACTION PATIENTS IN FIVE EDUCATION LEVELS AND ASSIGNMENT OF THERAPIST Education P s y c h i a t r i s t S o c i a l Worker n Less Grade 7 50.00 50.00 6 7-11 Years 58.5^ 41.46 82 High School 70.00 30.00 40 Technical 50.00 50.00 6 U n i v e r s i t y 70.29 29.41 17 T o t a l 62.25 37.75 151 x 2 = 2.772 P .70 df = 4 37 BIBLIOGRAPHY American Psychiatric Association. Diagnostic and Statistical Manual of  Mental Disorders! Washington, D. C . , 1952. B r i l l , N. and Storrow, H. "Social Class and Psychiatric Treatment". Mental Health of the Poor. The Free Press of Glencoe, New York. 1964. p. 68. Clausen, J . A. and Yarrow, M. R. Paths to the Mental Hospital. The  Journal of Social Issues, Vol. 11. Nov., 1955' pp.25-32. Hollingshead, A. B. Two-Factor Index of Social Position. Unpublished Paper. Yale University. 1957* Hollingshead and Redlich. Social Class and Mental Illness. Science Editions. John Wiley and Sons. New York. 1958. Imber, Nash and Stone. "Social Class and Duration of Psychotherapy". Journal of Clinical Psychology, Vol. 11. July, 1955* PP« 281-284. Landy, D. and Albert, R. S. "Waiting for Hospitalization: a study of persons placed on a hospital waiting l i s t and their families. Archives  of General Psychiatry. 1959- pp. 519-529 Levinger, G. Continuance in Casework and Other Helping Relationships: A Review of Current Research. Social Work, Vol. 5. No. 3. July, I960, pp. 40-51 McMahon, J . T. "The Working Class Psychiatric Patient: A Clinical View". Mental Health of the Poor. The Free Press of Glencoe, New York. 1964. p. 283. Maas, H. S. Five Fields of Social Service: Reviews of Research. National Association of Social Workers, inc. New York. 1966 Meyer, J . K. and Roberts, B. H. Family and Class Dynamics in Mental Illness. John Wiley and Sons, -New York. 1959« Moore, R. A. , Benedek, E . P. and Wallace, J . G. Social Class, Schizo-phrenia and the Psychiatrist. American Journal of Psychiatry, Vol. 20. August, 1963. pp. 149-154. Myers, J . K. and Schaffer, L . "Social Stratification and Psychiatric Practice: A Study of an Out-Patient Clinic". American Sociological  Review, Vol. 19. June, 195*+• PP« 307-310. 3 8 Pasamanick, B . , Roberts, ¥ . , Lemkau, P. and Kreuger, B. "A Survey of Mental Disease in an Urban Population: Prevalence by Race and Income". Mental Health of the Poor. The Free Press of Glencoe. New York. 1964. P. 39. Polansky, N. A. Social Work Research. University of Chicago Press. Chicago. I960. Porter, J . The Vertical Mosaic. University of Toronto Press. 1965* Riessman, F . , Cohen, J . and Pearl, A. Mental Health of the Poor. The Free Press of Glencoe. Collier, MacMillan Limited. London. 1964. Scheff, T. (ed.) Mental Illness and Social Processes. Harper and Row. New York. 1967- ' -Strole, Leo et. a l . Mental Health in the Metropolis. McGraw H i l l Inc. New York. 1962. pp. 140-252. Weiss, P. , Macauly, J . and Pincus, A. "Geographic Factors and the Release.of Patients from Mental Hospitals". American Journal of  Psychiatry, pp. 408-12. Whitmer, C. A. and Conover, C. G. "A Study of Crit ical Incidents in the Hospitalization of the Mentally 111". Social Work, Vol. 4, No. 1. 1959. 

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