Do Psychiatric Outpatients Need
Professionals? Paul Lowinger, MD
Richmond, California
A large majority of psychiatric outpatients (70 percent) could be diagnosed by nonprofessionals, and an even larger proportion, 80 percent, of 36 patients evaluated could be treated by nonprofessionals. Where the nonprofessional needed professional assistance to diagnose and treat the patient, it was a medical doctor rather than a mental health professional who was needed in every case except one. The 36 psychiatric outpatients a11 had "problems of daily living" rather than "real" psychiatric illness. An important viewpoint in physical health and mental health is that many diagnostic and therapeutic activities can be carried on by nonprofessionals-people without professional degrees or prolonged formal training. This had been given expression in the New Careers program as well as in community mental health services. '2 It is akin to the deprofessionalization of education and health proposed by Illich.3'4 A critical appraisal of the National Institute of Mental Health has identified the expenditure of large amounts of federal funds for the training of mental health professionals to perform servicel that could be carried out by nonprofessionals. This report by Chu and Trotter5 from the Center for the Study of Responsive Law is identified with other Ralph Nader consumer critiques. One of the arguments from this perspective is that there are real psychiatric illnesses, such as acute schizophrenia, organic brain disease and suicidal depression, calling for medication and hospitalization. These real illnesses require mental health and medical professionals. However, the vast majority of mental disturbances seen in outpatient clinics and offices are problems of daily living. Problems of daily living are primarily caused by current or past deprivation among the poor, the working class, women, homosexuals and racial minorities, all of whom are also affected by intra and interpersonal problems. Problems of daily living From the Departments of Psychiatry and Community Medicine, University of California School of Medicine, San Francisco, The Wright Institute, Berkeley, and Contra Costa County Mental Health Services, Richmond, California. This work was done when the author was Associate Clinical Professor of Psychiatry, Wayne State University, Detroit, and Research Director, Detroit Model Neighborhood Drug Abuse Program. Requests for reprints should be addressed to Dr. Paul Lowinger, 77 Belgrave Avenue, San Francisco, CA 94117.
among the middle and upper classes are
primarily caused by intra and interpersonal problems. The problems of daily living include issues of environment, employment, education, law and justice, drugs, marriage, family, community, as well as interpersonal and intrapersonal concerns. The book by Chu and Trotter suggests that these problems do not require psychiatrists, psychologists, nurses or social workers, but can be handled by nonprofessionals with human services training and experience. Instead, the National Institute of Mental Health, through the universities, has trained at great expense many mental health professionals who spend most of their time handling problems of daily living. Meanwhile, the real psychiatric illnesses that are the most disabling are treated by a small number of mental health professionals. It is this provocative thesis that leads to a re-evaluation of the patients coming to office and outpatient psychiatric facilities in order to determine how many have real psychiatric illness, and how many have a problem of daily living. An attempt is also made to determine whether nonprofessionals with training and experience could be effective in handling these patients and their problems, or whether they require highly trained professionals.
Method A survey by the author in two clinical settings using 36 initial interviews was the method in this preliminary study. The consecutive initial interviews after January 1, 1972, used for the study included 24 supervised by the author at Lafayette Clinic and 12 interviews from the author's private practice. The 24 psychiatric interviews
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 11, 1979
from Lafayette Clinic in Detroit were conducted by resident physicians and medical students and supervised by the author. Twelve of the author's own office psychiatric interviews in Detroit with private adult patients were also evaluated. The Lafayette Clinic is the clinical facility of a medical school department of psychiatry which offers training, research and clinical experience using a mental health professional staff. It offers low cost treatment to residents of Michigan and operates an adult outpatient clinic where these interviews were conducted. A standardized questionnaire about each of these interviews was completed by the author. A categorization of the 36 outpatients into real psychiatric illness and problems of daily living was made without regard to the psychiatric diagnosis. This classification was based on the need for extensive medical treatment, institutional care, or hospitalization in real psychiatric illness. Problems of daily living do not require these treatments, although the use of a medication such as a tranquilizer may be indicated.
Results The patients were 18 to 47 years of age with a median age of 26. There were 24 men and 12 women. Fifteen were single, four were married, and 17 were divorced, separated, or widowed. There were 27 white and nine black patients. The social class of the patients was broken down into the following: three in class two, 16 in class three, 16 in class four, and one in class five on the Hollingshead-Redlich scale of social class6 which is based on the occupation of the family breadwinner. There were no patients in the highest social class, one. The educational mean of the group was 13 years of school. The psychiatric diagnoses were 12 psychoneurotic disorders, 12 personality disorders, seven adult situational reactions, three schizophrenic reactions, one chronic brain syndrome, and one psychophysiologic reaction. The origins of the disorders of the 1095
patients were categorized as being rooted in one or more of five groups: medical illness, present or past deprivation, community factors, intrapersonal disturbance, and/or interpersonal disturbance. Five patients had medical conditions which played a role in their emotional illnesses, 15 patients were reacting to important community pressures, 24 patients had significant intrapersonal disturbances, and 27 patients had interpersonal disturbances. There were 80 categorizations for 36 patients, an average of 2.2 for each patient. An example of this categorization was a 42-year-old white female who had a childhood with a rejecting mother who favored her sister. Later, this patient had a brutal husband. She was divorced and had a reluctant boyfriend and considerable conflict with her daughter. She was on welfare, and her health was poor due to gastrointestinal symptoms. The patient was classified as having a significant medical illness, and intra and interpersonal problems, as well as past and present deprivation. Community disturbances also play a role in her life because she is subject to the poor self-esteem and the low status of the welfare recipient. There were no patients with a single category of etiology; however, a simpler example was that of a 25-year-old white divorced female whose main difficulties were her deprived background and an addiction to heroin which represented community dysfunction. These factors greatly outweighed her secondary intra and interpersonal disturbances and health problems. Another kind of patient was a 22-year-old white, married male student who had a neurotic disturbance based on sexual fears and a concern about latent homosexuality. His background included an overprotective mother and a repressive father. This patient's difficulties were categorized primarily as intra and interpersonal, while his concern about a community response to his feared homosexuality played a minor role. A judgment was made as to whether the initial interview could be conducted by a trained nonprofessional or whether a professional interviewer was necessary. The initial interview of 26 patients (72 percent) called for only the appraisal of a nonprofessional. Nine patients required nonprofessional appraisal combined with that of a medical doctor while one patient required the use of a psychiatrist or other mental 1096
health professional. When the opinion about the examiner was extended to the kind of therapist necessary to treat the patient, 29 patients (80 percent) required only a nonprofessional while seven patients required a nonprofessional and a medical doctor. There were no patients requiring a mental health professional for continued care. The decision as to whether a nonprofessional could evaluate and treat the emotional disorder of the patient or whether this would require a professional was based on the author's experience since 1950 working with and supervising professionals as well as nonprofessionals. Professional therapists are nearly always medical doctors, educators, clergy, psychiatrists, psychologists, social workers, or nurses. Nonprofessional therapists include psychiatric attendants, ex-addict counselors, and community workers. These models do not exhaust the categories and capacities of nonprofessional health and mental health workers; however, they exemplify the kind of experience, training and community responsibility that might be useful in a community mental health program. A separate judgment was made by the author about whether the 36 patients had real psychiatric illness or problems of daily living. All fell in the latter category despite the variety of diagnoses. Although about a quarter of the patients required some professional appraisal in diagnosis and a fifth needed professional assistance for treatment, there were none with a real psychiatric illness as defined by a need for extensive medical care or hospitalization. An exacerbation of schizophrenia requiring visits to a clinic may be as much related to problems of daily living as a situational reaction, even though schizophrenia is sometimes a real illness by our definition.
Discussion The role of the nonprofessional has been praised, explicated, and urged many times over. Traditional voices from the professional community have called for a restricted and subservient role for the nonprofessional. Some professionals have argued against all use of the nonprofessional in mental health programs. The reallocation of a preponderance of outpatient mental health responsibilities to nonprofessionals is a recent idea, but it is part of a new
concept-people taking full responsibility for their own health and mental health by access to the equipment including drugs, full possession of accumulated medical and psychiatric information, and the legal right to act. This deprofessionalizing of health suggested by Ivan Illich4 is quite different from the use of trained nonprofessionals. Both differ considerably from the proposed national health plans for the United States, which place heavy emphasis on professional expertise. Only the health plan of the People's Republic of China and the proposal of the Committee for a National Health Plan in the United States begin to recognize the importance of communal nonprofessional health workers. This report is a preliminary and subjective evaluation of the current capacity and potential of the nonprofessional in mental health in the United States. The nonprofessional mental health worker comes from a variety of experiences in black and other ethnic movements, family and community life, the drug culture, the women's movement, the gay community, alcoholism, and as 2 former mental patient. Thus, she or he may be a housewife from a suburb or an ethnic ghetto, an ex-addict, a worker in an abortion clinic, a member of Alcoholics Anonymous, a participant in mental patient liberation, or an indigenous community leader. In addition to the life and community background, certain training is important if the nonprofessional is to function in a clinic. The training often involves clinical responsibilities shared daily with nonprofessional peers and supervisors as well as professional consultants. Thus the potential for training through observation and supervised experience is realized. Nonprofessionals also need courses, seminars, and reading which improve their communication with the professionals. The women's abortion program in New York provides an example of new and creative use of nonprofessionals.7 Emotional support, patient advocacy, and quality control of the abortion experience is carried out by nonprofessional women with experience in abortion procedures and counseling. Another nonprofessional counselor, the ex-addict, begins clinical function with addict clients at the Detroit Model Neighborhood Drug Abuse Program, while she/he is in a six month training program that includes classes. Direct
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 11, 1979
experience as an addict on the streets and then in a treatment program as an ex-addict is the basis of the function, although she/he continues to review cases and be supervised-mostly by nonprofessionals. The availability of consultants for the nonprofessionals and their clients in addiction programs includes specialists in family medicine, psychiatry, vocational rehabilitation, social work, and education. It is this kind of nonprofessional and her/his consultants who would assume responsibility for the vast majority of ambulatory psychiatric "illness" which comes to clinics, offices, and community mental health centers. Medical doctors and specialized mental health professionals would assume responsibility as consultants (not supervisors) to the nonprofessionals in dealing with problems of daily living. Medically trained psychiatrists and other mental health professionals would assume the major responsibility in the real psychiatric illness where hospitalization and the extensive use of drugs are indicated. Such a reappraisal of the responsibilities of mental health personnel suggests radically different mental health priorities for states, universities,
and the National Institute of Mental Health. The present state of affairs would be reversed. This means the bulk of the training and personnel budget would be for the support of nonprofessionals because their role would be more limited. The delineation of the specific problems of daily living for each patient is meant to rationalize the assignment of these patients to nonprofessionals. This is an attempt to deal with the question of etiology unencumbered by traditional, unproved, and restrictive psychiatric, psychologic, and psychoanalytic theory. This is not a commentary on the correctness or error of the great variety of theories available from these disciplines. The simplification, rationalization, and verification of psychiatric theories about etiology is necessary regardless of whether psychiatric diagnosis and treatment is carried out by professionals or nonprofessionals. A theory about problems of daily living as etiologic of the disorders in these patients is not mutually exclusive with more complex and traditional psychiatric explanations of the development of emotional disturbance. Nonetheless the presence of an operational and
understandable framework for the deprofessionalization of outpatient mental health activities is useful. Meanwhile, community studies of mental and emotional disturbance place considerable emphasis on the role of environmental factors. 8-14 Literature Cited 1. Alley S, Blanton J: Paraprofessionals in Mental Health. Berkeley, California, Social Action Research Center, 1978 2. Hines L: A nonprofessional discusses her role in mental health. Am J Psychiatry
126:1467-1472,-1970
3. Illich l: Deschooling Society. New York, Harper and Row, 1971 4. lllich l: Medical Nemesis. New York, Pantheon Books, 1976 5. Chu R, Trotter S: The Madness Establishment. New York, Grossman Publishers, 1974 6. Hollingshead A, Redlich F: Social Class and Mental Illness. New York, John Wiley and Sons, 1963 7. Frankfort E: Vaginal Politics. New York, Quadrangle Books, 1972 8. Langner T, Michael S: Life Stress and Mental Health. New York, Crowell-Collier, 1963 9. Reissman F, Cohen J, Pearl A: Mental Health of the Poor. New York, Crowell-Collier, 1963 10. Dubos R: Man Adapting. New Haven, Connecticut, Yale University Press, 1965 11. Grier W, Cobbs P: Black Rage. New York, Basic Books, 1968 12. Mechanic D: Medical Sociology: A Selective View. New York, Free Press, 1968 13. Kosa J, Antonovsky A, Zola I: Poverty and Health. Cambridge, Massachusetts, Harvard University Press, 1969 14. Lehmann S: Selcted self-help: A study of clients of a community social psychiatry service. Am J Psychiatry 126:1444-1454, 1970
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 11, 1979
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Professionals? Paul Lowinger, MD
Richmond, California
A large majority of psychiatric outpatients (70 percent) could be diagnosed by nonprofessionals, and an even larger proportion, 80 percent, of 36 patients evaluated could be treated by nonprofessionals. Where the nonprofessional needed professional assistance to diagnose and treat the patient, it was a medical doctor rather than a mental health professional who was needed in every case except one. The 36 psychiatric outpatients a11 had "problems of daily living" rather than "real" psychiatric illness. An important viewpoint in physical health and mental health is that many diagnostic and therapeutic activities can be carried on by nonprofessionals-people without professional degrees or prolonged formal training. This had been given expression in the New Careers program as well as in community mental health services. '2 It is akin to the deprofessionalization of education and health proposed by Illich.3'4 A critical appraisal of the National Institute of Mental Health has identified the expenditure of large amounts of federal funds for the training of mental health professionals to perform servicel that could be carried out by nonprofessionals. This report by Chu and Trotter5 from the Center for the Study of Responsive Law is identified with other Ralph Nader consumer critiques. One of the arguments from this perspective is that there are real psychiatric illnesses, such as acute schizophrenia, organic brain disease and suicidal depression, calling for medication and hospitalization. These real illnesses require mental health and medical professionals. However, the vast majority of mental disturbances seen in outpatient clinics and offices are problems of daily living. Problems of daily living are primarily caused by current or past deprivation among the poor, the working class, women, homosexuals and racial minorities, all of whom are also affected by intra and interpersonal problems. Problems of daily living From the Departments of Psychiatry and Community Medicine, University of California School of Medicine, San Francisco, The Wright Institute, Berkeley, and Contra Costa County Mental Health Services, Richmond, California. This work was done when the author was Associate Clinical Professor of Psychiatry, Wayne State University, Detroit, and Research Director, Detroit Model Neighborhood Drug Abuse Program. Requests for reprints should be addressed to Dr. Paul Lowinger, 77 Belgrave Avenue, San Francisco, CA 94117.
among the middle and upper classes are
primarily caused by intra and interpersonal problems. The problems of daily living include issues of environment, employment, education, law and justice, drugs, marriage, family, community, as well as interpersonal and intrapersonal concerns. The book by Chu and Trotter suggests that these problems do not require psychiatrists, psychologists, nurses or social workers, but can be handled by nonprofessionals with human services training and experience. Instead, the National Institute of Mental Health, through the universities, has trained at great expense many mental health professionals who spend most of their time handling problems of daily living. Meanwhile, the real psychiatric illnesses that are the most disabling are treated by a small number of mental health professionals. It is this provocative thesis that leads to a re-evaluation of the patients coming to office and outpatient psychiatric facilities in order to determine how many have real psychiatric illness, and how many have a problem of daily living. An attempt is also made to determine whether nonprofessionals with training and experience could be effective in handling these patients and their problems, or whether they require highly trained professionals.
Method A survey by the author in two clinical settings using 36 initial interviews was the method in this preliminary study. The consecutive initial interviews after January 1, 1972, used for the study included 24 supervised by the author at Lafayette Clinic and 12 interviews from the author's private practice. The 24 psychiatric interviews
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 11, 1979
from Lafayette Clinic in Detroit were conducted by resident physicians and medical students and supervised by the author. Twelve of the author's own office psychiatric interviews in Detroit with private adult patients were also evaluated. The Lafayette Clinic is the clinical facility of a medical school department of psychiatry which offers training, research and clinical experience using a mental health professional staff. It offers low cost treatment to residents of Michigan and operates an adult outpatient clinic where these interviews were conducted. A standardized questionnaire about each of these interviews was completed by the author. A categorization of the 36 outpatients into real psychiatric illness and problems of daily living was made without regard to the psychiatric diagnosis. This classification was based on the need for extensive medical treatment, institutional care, or hospitalization in real psychiatric illness. Problems of daily living do not require these treatments, although the use of a medication such as a tranquilizer may be indicated.
Results The patients were 18 to 47 years of age with a median age of 26. There were 24 men and 12 women. Fifteen were single, four were married, and 17 were divorced, separated, or widowed. There were 27 white and nine black patients. The social class of the patients was broken down into the following: three in class two, 16 in class three, 16 in class four, and one in class five on the Hollingshead-Redlich scale of social class6 which is based on the occupation of the family breadwinner. There were no patients in the highest social class, one. The educational mean of the group was 13 years of school. The psychiatric diagnoses were 12 psychoneurotic disorders, 12 personality disorders, seven adult situational reactions, three schizophrenic reactions, one chronic brain syndrome, and one psychophysiologic reaction. The origins of the disorders of the 1095
patients were categorized as being rooted in one or more of five groups: medical illness, present or past deprivation, community factors, intrapersonal disturbance, and/or interpersonal disturbance. Five patients had medical conditions which played a role in their emotional illnesses, 15 patients were reacting to important community pressures, 24 patients had significant intrapersonal disturbances, and 27 patients had interpersonal disturbances. There were 80 categorizations for 36 patients, an average of 2.2 for each patient. An example of this categorization was a 42-year-old white female who had a childhood with a rejecting mother who favored her sister. Later, this patient had a brutal husband. She was divorced and had a reluctant boyfriend and considerable conflict with her daughter. She was on welfare, and her health was poor due to gastrointestinal symptoms. The patient was classified as having a significant medical illness, and intra and interpersonal problems, as well as past and present deprivation. Community disturbances also play a role in her life because she is subject to the poor self-esteem and the low status of the welfare recipient. There were no patients with a single category of etiology; however, a simpler example was that of a 25-year-old white divorced female whose main difficulties were her deprived background and an addiction to heroin which represented community dysfunction. These factors greatly outweighed her secondary intra and interpersonal disturbances and health problems. Another kind of patient was a 22-year-old white, married male student who had a neurotic disturbance based on sexual fears and a concern about latent homosexuality. His background included an overprotective mother and a repressive father. This patient's difficulties were categorized primarily as intra and interpersonal, while his concern about a community response to his feared homosexuality played a minor role. A judgment was made as to whether the initial interview could be conducted by a trained nonprofessional or whether a professional interviewer was necessary. The initial interview of 26 patients (72 percent) called for only the appraisal of a nonprofessional. Nine patients required nonprofessional appraisal combined with that of a medical doctor while one patient required the use of a psychiatrist or other mental 1096
health professional. When the opinion about the examiner was extended to the kind of therapist necessary to treat the patient, 29 patients (80 percent) required only a nonprofessional while seven patients required a nonprofessional and a medical doctor. There were no patients requiring a mental health professional for continued care. The decision as to whether a nonprofessional could evaluate and treat the emotional disorder of the patient or whether this would require a professional was based on the author's experience since 1950 working with and supervising professionals as well as nonprofessionals. Professional therapists are nearly always medical doctors, educators, clergy, psychiatrists, psychologists, social workers, or nurses. Nonprofessional therapists include psychiatric attendants, ex-addict counselors, and community workers. These models do not exhaust the categories and capacities of nonprofessional health and mental health workers; however, they exemplify the kind of experience, training and community responsibility that might be useful in a community mental health program. A separate judgment was made by the author about whether the 36 patients had real psychiatric illness or problems of daily living. All fell in the latter category despite the variety of diagnoses. Although about a quarter of the patients required some professional appraisal in diagnosis and a fifth needed professional assistance for treatment, there were none with a real psychiatric illness as defined by a need for extensive medical care or hospitalization. An exacerbation of schizophrenia requiring visits to a clinic may be as much related to problems of daily living as a situational reaction, even though schizophrenia is sometimes a real illness by our definition.
Discussion The role of the nonprofessional has been praised, explicated, and urged many times over. Traditional voices from the professional community have called for a restricted and subservient role for the nonprofessional. Some professionals have argued against all use of the nonprofessional in mental health programs. The reallocation of a preponderance of outpatient mental health responsibilities to nonprofessionals is a recent idea, but it is part of a new
concept-people taking full responsibility for their own health and mental health by access to the equipment including drugs, full possession of accumulated medical and psychiatric information, and the legal right to act. This deprofessionalizing of health suggested by Ivan Illich4 is quite different from the use of trained nonprofessionals. Both differ considerably from the proposed national health plans for the United States, which place heavy emphasis on professional expertise. Only the health plan of the People's Republic of China and the proposal of the Committee for a National Health Plan in the United States begin to recognize the importance of communal nonprofessional health workers. This report is a preliminary and subjective evaluation of the current capacity and potential of the nonprofessional in mental health in the United States. The nonprofessional mental health worker comes from a variety of experiences in black and other ethnic movements, family and community life, the drug culture, the women's movement, the gay community, alcoholism, and as 2 former mental patient. Thus, she or he may be a housewife from a suburb or an ethnic ghetto, an ex-addict, a worker in an abortion clinic, a member of Alcoholics Anonymous, a participant in mental patient liberation, or an indigenous community leader. In addition to the life and community background, certain training is important if the nonprofessional is to function in a clinic. The training often involves clinical responsibilities shared daily with nonprofessional peers and supervisors as well as professional consultants. Thus the potential for training through observation and supervised experience is realized. Nonprofessionals also need courses, seminars, and reading which improve their communication with the professionals. The women's abortion program in New York provides an example of new and creative use of nonprofessionals.7 Emotional support, patient advocacy, and quality control of the abortion experience is carried out by nonprofessional women with experience in abortion procedures and counseling. Another nonprofessional counselor, the ex-addict, begins clinical function with addict clients at the Detroit Model Neighborhood Drug Abuse Program, while she/he is in a six month training program that includes classes. Direct
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 71, NO. 11, 1979
experience as an addict on the streets and then in a treatment program as an ex-addict is the basis of the function, although she/he continues to review cases and be supervised-mostly by nonprofessionals. The availability of consultants for the nonprofessionals and their clients in addiction programs includes specialists in family medicine, psychiatry, vocational rehabilitation, social work, and education. It is this kind of nonprofessional and her/his consultants who would assume responsibility for the vast majority of ambulatory psychiatric "illness" which comes to clinics, offices, and community mental health centers. Medical doctors and specialized mental health professionals would assume responsibility as consultants (not supervisors) to the nonprofessionals in dealing with problems of daily living. Medically trained psychiatrists and other mental health professionals would assume the major responsibility in the real psychiatric illness where hospitalization and the extensive use of drugs are indicated. Such a reappraisal of the responsibilities of mental health personnel suggests radically different mental health priorities for states, universities,
and the National Institute of Mental Health. The present state of affairs would be reversed. This means the bulk of the training and personnel budget would be for the support of nonprofessionals because their role would be more limited. The delineation of the specific problems of daily living for each patient is meant to rationalize the assignment of these patients to nonprofessionals. This is an attempt to deal with the question of etiology unencumbered by traditional, unproved, and restrictive psychiatric, psychologic, and psychoanalytic theory. This is not a commentary on the correctness or error of the great variety of theories available from these disciplines. The simplification, rationalization, and verification of psychiatric theories about etiology is necessary regardless of whether psychiatric diagnosis and treatment is carried out by professionals or nonprofessionals. A theory about problems of daily living as etiologic of the disorders in these patients is not mutually exclusive with more complex and traditional psychiatric explanations of the development of emotional disturbance. Nonetheless the presence of an operational and
understandable framework for the deprofessionalization of outpatient mental health activities is useful. Meanwhile, community studies of mental and emotional disturbance place considerable emphasis on the role of environmental factors. 8-14 Literature Cited 1. Alley S, Blanton J: Paraprofessionals in Mental Health. Berkeley, California, Social Action Research Center, 1978 2. Hines L: A nonprofessional discusses her role in mental health. Am J Psychiatry
126:1467-1472,-1970
3. Illich l: Deschooling Society. New York, Harper and Row, 1971 4. lllich l: Medical Nemesis. New York, Pantheon Books, 1976 5. Chu R, Trotter S: The Madness Establishment. New York, Grossman Publishers, 1974 6. Hollingshead A, Redlich F: Social Class and Mental Illness. New York, John Wiley and Sons, 1963 7. Frankfort E: Vaginal Politics. New York, Quadrangle Books, 1972 8. Langner T, Michael S: Life Stress and Mental Health. New York, Crowell-Collier, 1963 9. Reissman F, Cohen J, Pearl A: Mental Health of the Poor. New York, Crowell-Collier, 1963 10. Dubos R: Man Adapting. New Haven, Connecticut, Yale University Press, 1965 11. Grier W, Cobbs P: Black Rage. New York, Basic Books, 1968 12. Mechanic D: Medical Sociology: A Selective View. New York, Free Press, 1968 13. Kosa J, Antonovsky A, Zola I: Poverty and Health. Cambridge, Massachusetts, Harvard University Press, 1969 14. Lehmann S: Selcted self-help: A study of clients of a community social psychiatry service. Am J Psychiatry 126:1444-1454, 1970
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