Manhattan Madness

Mental Health in the Metropolis, The Midtown Manhattan Study (Volume I).
by Leo Srole, Thomas S. Langner, Stanley T. Michael, Marvin K. Opler, and Thomas A. C. Rennie.
McGraw-Hill. 428 pp. $9.95.

“The Midtown Investigation, beyond any question, was large in focus, goals, strategy, and operational scope,” the senior author of this book asserts in his epilogue. So, indeed, it was. Sampling a population of 110,000 residents in a mid-Manhattan district described as a “sociographically well delineated residential area near the epicenter of New York City’s hub borough of Manhattan,” the study employed several massive procedures for data collection. If the reader is at all interested in the results of this important and highly publicized research, it is important that he understand these procedures with some precision; because some of the more widely accepted implications of the study depend, I believe, on a partial misunderstanding of its data.

The authors are meticulous enough in cautioning the reader. “The keystone of the entire study was the Home Interview Survey,” in which 1,911 residents were selected as a rigorously randomized sample of the 110,000; 1,660 of these were actually interviewed, which is a highly satisfactory proportion in such a study. Demographically, Midtown checks out as virtually identical with the rest of Manhattan, except that very few Negroes and not many Puerto Ricans live there. Like the rest of Manhattan, it contrasts sharply with the other boroughs in having a much smaller proportion of children and a larger proportion of single individuals. And, as the authors literally stress by their italics: “Throughout the volumes of this Study, the data must be evaluated as a rating of mental health based on the rating psychiatrists’ perceptions operating through a questionnaire instrument.”

This is the heart of the matter. The authors are at some pains—they seem almost obsessive-compulsive—to examine the weaknesses and biases of their procedures honestly. Indeed, it may well be as a case-study in self-conscious research methodology that this book will have its greatest value; the chapters in the prologue on design are as subtle in their self-questioning as the musings of a Dostoevsky character, though Dostoevsky’s work enjoys the advantage of translation into excellent English. But more is at issue here than the validity of the questionnaire, or of a process in which mental health is assessed by psychiatrists who have never seen the patient from whom data were gathered. It is true, as the authors note, that the questionnaire procedure, thus applied, precludes any assessment of mental illness in the usual psycho-dynamic terms. But they also commit the authors implicitly to a position as to the nature of mental illness and of its social function.

Under these circumstances, the questionnaire functions as an inventory of symptoms. The symptoms selected are valid signs of emotional disturbance even though, by themselves, they reveal very little about its nature. The reader must agree, I think, that the individuals rated as “Impaired” by the instrument doubtless were. There is more doubt, however, about those rated “Well,” “Mild,” or “Moderate.” The mental health of the comparatively well-educated and well-to-do probably shows up on this instrument as better than it actually is, because the language of the questionnaire is essentially one long working-class whine.

The authors of this Study guard very carefully against introducing class bias. They discuss their precautions in detail in Appendix H: among others, “so far as it was practically possible, it was our policy to assign each interviewer to respondents of the SES (socio-economic status) range and ethnic background closest to his family or professional experience.” Yet how could even this precaution avail against a questionnaire that asks “stomach upset pretty often,” “Felt weak all over,” “Bothered by sour stomach several times a week,” “One drink is one too many.” There seem to have been no questions about piles or getting up nights; there were certainly none about the stock-market, or bad schools, or civil liberties, all of which are good, sound points of crystallization for middle-class anxiety.

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Settling for a working-class frame of reference is usually justified as necessary to yield comparable results: vocabulary and concepts must be limited to what all the respondents can understand. But, on the basis of the much more sophisticated treatment of Hollingshead and Redlich in the New Haven Study, which the authors frequently cite, it seems obvious that the terms—and the symptoms—in which different social classes express their illness are not mutually comprehensible. Indeed, this is a major source of difficulty in their efforts to live together.

What the Home Interview Survey primarily observed then, it seems to me, was the tendency for life in Midtown to make people nervous. It does. One of the genuinely comical aspects of the book is the authors’ efforts to reconcile their findings to the much lower incidences of mental illness reported in studies of other populations. The authors write as if they assumed that it is the discrepancy that must be explained, since their readers could hardly be expected to believe that people in Midtown really were sicker. New York, remains, however, a wonderful place to visit.

The most important findings of the Study, and the most stressed, are the positive relations between mental health as here observed and SES; and the negative relation between mental health and age. Nobody could cavil at these findings. In one subway trip out of three, at least, one encounters a poor, old man or woman in obvious distress and often apparently psychotic; the younger and richer, though not always more agreeable, do clearly more frequently have their wits about them. Mr. Srole, in his epilogue, “Sociologist’s Sight Lines: Retrospective and Prospective,” expresses his compassion for these victims and his insight into the sources of their degradation in the characteristic language of the volume: “In the stigmatize-rejection mechanism here considered pathogenic for its objects, we confront the entire evaluative apparatus of the society’s status-allocating system.” Who would deny it? Mental Health in the Metropolis does not exaggerate the plight of the aged poor in Midtown. Dante himself could not have exaggerated it. But it does, I believe, grossly underestimate the impairment of the “more fortunate.”

Partly, the reason lies in the tendency of the questionnaire to enumerate diffuse suspicion and physical symptoms, which are essentially lower-status modes of expressing anxiety. As Hollingshead and Redlich put it: “the class V [lowest] neurotic behaves badly, the IV neurotic aches physically, the class III patient defends fearfully, and the class I—II patient is dissatisfied with himself.” The Home Interview Survey would, I believe, respond more sensitively to the symptoms of classes III-V than to classes I and II. But a much more basic source of distortion than any bias in the inventory of items is the fact that it if an inventory: that it takes account of symptoms rather than of character and personality.

The most serious consequence of starting with a catalogue of symptoms, is that the authors then perceive mental health as wholly normative. Their formal definition of mental health is sound enough, and not normative: Rennie, who guided the Study for four years prior to his untimely death, explicitly conceived mental health in dynamic terms. But the concept drops out in the methodology, and leaves the Study staff Studying not mental health, but adjustment.

What is lacking in the work is anything approaching Erich Fromm’s conception of a socially-patterned defective character. Socially-patterned defectives don’t have symptoms; they are symptoms. As long as they are functioning in their accustomed society they are not nervous and they are not seen as inadequate; they succeed. Until thalidomide blew up, Dr. Kelsey almost certainly showed more nervous symptoms than her Food and Drug Administration superiors or the salesmen who were pressuring her. Yet we still believe, with some reason, that integrity is a sign of health, and the strength to maintain it under stress, when the stomach turns sour and the palms sweat, a sign of greatest health of all.

This consideration strikes, I feel, at the plausibility of the authors’ central inferences. They emphasize, for example, their disagreement with what they take to be sociology’s—as exemplified by Seymour Lipset’s—position that social mobility is often both a source and an expression of emotional stress in the form of anxious striving. These authors, on the contrary, find the best mental health among the successfully upward mobile and the poorest among descenders in the social scale. They interpret this observation—undoubtedly correctly—as circular; not only are achievement and promotion soothing and gratifying in themselves; but nervousness, rigidity, and passive hostility are formidable barriers to advancement. Success, certainly, is partly the acting-out of a self-fulfilling prophecy. Confidence leads to success, and the confident are not nervous. But they are not necessarily healthier than the worried.

So the implications drawn by the authors of Mental Health in the Metropolis must, I think, be interpreted with reserve. But the work nevertheless remains exceptionally impressive both in its scope and in its methodological rigor. Its most impressive finding—and this one seems unimpeachable—is precisely the one that has received most publicity: the incredibly high rate of impairment in Midtown generally. Eighteen and one-half per cent of the respondents rated as Well, and this is probably an overestimate. Nearly a quarter are grossly impaired, 36 per cent show Mild, and 22 per cent Moderate symptom formation. The cliché, it appears, is right. So marked an evolutionary development must have some adaptive value. You don’t have to be crazy to live in New York, but it helps.

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