Both social class and mental illness may be compared with an iceberg; 90% of it is concealed below the surface. The submerged portion, though unseen, is the dangerous part. This may be illustrated by recalling what happened when an “unsinkable” trans-Atlantic luxury liner, the Titanic, rammed an iceberg on her maiden voyage in 1912. In that crisis, a passenger’s class status played a part in the determination of whether he survived or was drowned. The official casualty list showed that only 4 first class female passengers (3 voluntarily chose to stay on the ship) of a total of 143 were lost. Among the second class passengers, 15 of 93 females drowned; and among the third class, 81 of 179 female passengers went down with the ship. The third class passengers were ordered to remain below deck, some kept there at the point of a gun.
The idea that stratification in our society has any bearing on the diagnosis and treatment of disease runs counter to our cherished beliefs about equality, especially when they are applied to the care of the sick. Physicians have deeply ingrained egalitarian ideals with their fellow citizens, yet they, too, may make subtle, perhaps unconscious judgments of the differential worth of the members of our society. Physicians, among them psychiatrists, are sensitive to statements that patients may not be treated alike; in fact there is strong resistance in medical circles to the exploration of such questions. But closing our eyes to facts or denying them in anger will help patients no more than the belief that the Titanic was “unsinkable” kept the ship afloat after it collided with an iceberg. . . .
The implementation of a decision that a person should be treated by a psychiatrist for his disturbed behavior is linked to class status. There is a definite tendency to induce disturbed persons in class I [the most affluent class, highly educated, consisting of business and professional leaders] and II [generally educated beyond high school, managerial positions, living in the better neighborhoods] to see a psychiatrist in more gentle and “insightful” ways than is the practice in class IV [the working class, engaged in skilled or semi-skilled manual occupations, generally completed some high school] and especially in class V [the lowest class; semiskilled factory hands and unskilled laborers who generally have not completed elementary school, living in the worst areas of town], where direct, authoritative, compulsory, and, at times, coercively brutal methods are used. We see this difference most frequently in forensic cases of mentally ill persons who are treated often according to their class status. The goddess of justice may be blind, but she smells differences, and particularly class differences. In sum, perception of trouble, its evaluation, and decisions about how it should be regarded are variables that are influenced in highly significant ways by an individual’s class status. . . .
[A] distinct inverse relationship does exist between social class and mental illness. The linkage between class status and the distribution of patients in the population follows a characteristic pattern; class V, almost invariably, contributes many more patients than its proportion in the population warrants. Among the higher classes there is a more proportionate relationship between the number of psychiatric patients and the number of individuals in the population. . . .
Hollingshead AB, Redlich FC
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