The first edition of this book (1966) presented a sociological theory of mental disorder. Seeing mental disorder from the point of view of a single discipline, the theory was one-dimensional. The second edition (1984), except for slight changes, continued in this same vein. Since that time there have been substantial advances in the biology, psychology, and even in the sociology of mental disorder. What is now most needed is an interdisciplinary approach, one that would integrate the disparate languages, viewpoints, and findings of the relevant disciplines. Such an integrated approach would be far greater than the sum of its parts, the separate disciplines. In human conduct, particularly, the vital processes seem to occur at interfaces, in the intersections of organic, psychological, and social systems.
To use E. O. Wilson’s term (1998), what we want is "consilience," the interlocking of frameworks from the relevant disciplines. Although not using that word, I had proposed a similar interlocking for the social sciences (Scheff 1997) and illustrated what it would look like with several of my own studies. As Wilson indicates, many of the recent triumphs of the physical and life sciences have been based on the integration of the various disciplinary approaches.
As Wilson also indicates, there has been very little consilience among the behavioral and social sciences. Each of these disciplines goes its own way, ignoring the adjacent disciplines. Each emphasizes its own virtues, largely ignoring its weaknesses, as in the old song: "You got to accentuate the positive, eliminate the negative, tune in to the affirmative, don’t mess with Mr. Inbetween." Contrary to the song, we must begin to mess with Mr. Inbetween.
Given the need for consilience, is there any point in resurrecting labeling theory, yet another one-dimensional approach to the complex problem of mental disorder? Before preparing this edition, I worried this issue. My decision that the theory still had value was based on the following ideas. First, while waiting for consilient approaches to be developed, headway can still be made with one- or two-dimensional approaches. As will be proposed in Chapter 1, biopsychiatry, an integration of biology and psychiatry, seems to have made many worthwhile advances in the understanding and treatment of mental disorder. In the last twenty years, even one-dimensional studies of labeling of mental disorder have made contributions to our understanding, as in the work of Bruce Link and his colleagues. When consilient theories are developed, there will still be a need for approaches that are only one- or two-dimensional.
A second idea may be just as important, that of the devil’s advocate. Biopsychiatry, the dominant force in the field, like all disciplines, accentuates the positive. Labeling theory can be considered to be a counter-theory, critical of the weakest points in the dominant theory, and focusing on issues that it neglects. The two approaches can complement and correct each other, while we are awaiting Mr. Inbetween.
The original theory of mental illness presented in this book had its high water mark in the 1970’s, if perhaps only as a counter-theory. During that decade labeling was taken seriously in sociology and, to a lesser extent in anthropology, criminology, psychology, psychiatry, and social work. Its status began to wane in the next decade, and by the beginning of the 1990’s it had been all but dismissed by the mainstream disciplines. As we shall see in Chapter 1, there are still proponents of the theory. But the majority of scholars and practitioners have moved on to other interests.
There are two main reasons for the loss of interest. The most important is what is called popularly "the tranquilizer revolution," and the accompanying rise of biological psychiatry. Beginning in the 1980’s and reaching its peak in the mid-90’s, most social scientists and practitioners formed the impression that the problem of mental illness had been solved, at least in principle. The public was persuaded by claims that the causes and treatment of mental illness had been shown to be biological. It was thought, and still is by many, that genetic causes of mental illness had been, or would shortly would be, found, and that psychoactive drugs could cure, or at least safely control, the symptoms of metal illness.
The first part of Chapter 1 will be devoted to exploring these claims. It seems now that although biological psychiatry has made advances, in the main its claims have still not been sufficiently substantiated. These matters are too complex to deal with briefly, so will be raised in the next chapter.
A second reason for the declining interest in the theory were various critiques proposing that since labeling theory was not substantiated by empirical studies, it should be abandoned. The most important of these critiques were those by Gove (1980; 1982). As with biological psychiatry, it now appears that the critiques of the labeling theory of mental illness were overstated. In Chapter 1, I will respond to Gove’s critique.
The research on which the earlier editions of this book were based on studies conducted during the period 1960-1982. Since that time, there have been many extraordinary changes in the field of mental illness: the introduction of psychoactive drugs on a massive scale; the discovery of the neurotransmitters; the hope to find genetic causes of mental illness; the proliferation and development of psychological therapies; changes in the mental health laws governing commitment and treatment; and finally, a sizeable increase in the number and scope of social scientific studies of mental illness. (For a description of the effect of the first edition of this book on mental health laws, see the Appendix.) This edition updates the earlier ones, bringing these changes and their aftereffects into its purview.
In addition to these changes in the field since 1984, there have also been changes in my own point of view since the time of the first edition. First, the changes related to my work on catharsis of emotions, as reflected in the book on this topic (1979). Secondly, my studies of the emotions of pride and shame (Scheff 1990; 1994; 1997; Scheff and Retzinger 1991), and the link between these emotions and the state of the social bond. Third, my interest in connecting the world of every day life to the larger institutions in a society has directed my attention to dialogue as data (Scheff 1990; 1997). Finally, mostly as a result of my dialogue studies, I now think, like Wilson (1998) that it is imperative to integrate the separate disciplines that deal with human behavior.
These changes in point view have had three main effects on this edition. First, they have led me to more strongly emphasize that the original labeling theory of mental illness, as presented in Chapters 3-5 below, is only one of many partial points of view. Each of these points of view is useful, but in the long run, it will be necessary to integrate the differing standpoints, especially the psychological, sociological, and biological approaches.
The second change involves increased emphasis on emotions and social bonds. The original theory was predominately cognitive and behavioral. In this edition, emotions and relationships are introduced, with a special emphasis on the emotion of shame as a key component in stigma and in the generation of the societal reaction to deviance. I now emphasize the role of pride/shame as Durkheim’s "social emotion," and the interplay of these emotions with social bonds. Since emotions and bonds are biological, psychological, and social, increasing emphasis on the emotional/relational world, largely invisible in Western civilization, may offer a bridge between the disciplines. The original labeling theory was blind to the emotional/relational world; it dealt only with extremes of societal labeling and denial. In this edition, I extend the theory to include more subtle forms of interaction.
Two of the new chapters (8 and 9) illustrate the emotional/relational world by applying labeling theory to the social interaction between therapist and patient. Chapter 8 involves a psychotherapy session between an anorexic woman, "Rhoda," and her therapist. The patient reports discourse in her family, especially dialogues between herself and her mother. This dialogue suggests that labeling of the patient occurred first in the family, before any formal labeling took place. This chapter points towards a modification and extension of the original theory.
Chapter 9 concerns the first meeting between an outpatient, "Martha," and a psychiatrist. It turns into a sparring match between the patient, who want to convey her emotional/relational world, and the psychiatrist, who wants to ascertain the facts. This interview exactly reverses the situation between therapist and client from that of the session in Chapter 8. In the latter session, it is the therapist who seeks to interest the client in her emotional/relational world. In the session in Chapter 9, it is the patient who tries to interest the psychiatrist in her (the patient’s) emotional world. Because of her skill and patience, "Rhoda’s" therapist is successful; she introduces her patient to the world of emotions. Martha’s therapist, however, remains oblivious.
With respect to the original theory of labeling, after due consideration, I decided to revise mainly by addition rather than by making large changes in the original text (Chapters 3-5). A new Chapter 1 takes up the issues raised above about the perspective of biological psychiatry, on the one hand, and critiques of labeling theory, on the other. Because I was unable to find a very concise statement of the theory of social control, I wrote a new chapter for the second edition (Chapter 2), stating the main elements of social control and relating them to deviance and to mental illness.
I have resisted the temptation to make large changes in the text outlining the theory that was published in 1966 because it may still be useful in its original form. Since the discovery of the role of the neurotransmitters, and the impetus to genetic research provided by DNA, researchers who investigate schizophrenia and the other major mental illnesses believe that they are now asking the right questions, and that knowledge of the causes and cures of the major mental illnesses will be uncovered within their own lifetimes. This research, which grew out of the use of psychoactive drugs, has also convinced many psychiatrists that these drugs not only are important in the treatment of mental illness but also hold the key to the understanding and conquest of these problems. These are heady times for biological theories of mental disorder.
Although their hypotheses are plausible, they are still, at this writing, unproven. To date, no clearly demonstrable linkage between neurotransmission or genetics has been found for any major mental illness. The idea that the mentally ill suffer from deficient neurotransmission or genes is only a theory. Furthermore, even if the connection were made, most of the basic issues involving the social control of mental illness would remain. Since the connection is still hypothetical, it is premature to discard labeling theory.
The same reasoning applies to what has been popularly called the "tranquilizer revolution."As will be discussed in Chapter 1, even the most useful of the psychoactive drugs do not cure mental illness- they alleviate the symptoms. And again, even if a drug treatment were found that could cure mental illness, the fundamental issues of social control would remain. When the painkilling properties of morphine were discovered, physicians called it "God's Own Medicine" because they thought it was a cure. It took many years to realize that it was only a painkiller. There may be a parallel to be drawn between the discovery of morphine and that of psychoactive drugs. It has been less than fifty years since the large-scale use of tranquilizers began. It may still be too early to evaluate their overall effects.
I am not arguing that the neurotransmitter hypothesis is incorrect, or that drugs are worthless; I am only suggesting that it is much too early to discard labeling theory, despite the significant gains that have been made. Some balance is required in evaluating the competing claims of both the somatic and the social theorists. In its heyday, there was a tendency in sociology to overstate the claims of labeling theory. To avoid overstatement, in the 1984 edition I made two changes in the original text. First, I relinquished the "single most important" phrase in Proposition 9, stating instead that labeling is among the most important causes. The issue of the order of importance of the various causes is empirical anyway and should not have been reduced to a theoretical claim.
The second change involves qualifying the contrast between the two poles of the societal reaction. Originally, I called the reaction to deviance that was opposite to labeling "denial"; in this edition I have changed it to "normalization." In fact, denial is only one of many differing ways of reacting to deviance, such as rationalization, ignoring, and temporizing.
In the context of mental disorder it is important to note that treatment is not necessarily a labeling reaction. Labeling, in the sense I use it, always involves stigmatization; there is an emotional response as well as special label. Any form of response which does not stigmatize, such as skillful and humane psychotherapy and hospitalization, may also be a form of normalization. In some ways, the term labeling itself is perhaps unfortunate, since it has become fashionable to apply it to mere classification. What is needed is a more forceful term, one that would connote both labeling and stigmatization, so that a distinction could be made between reintegrative and rejecting classification, as in Braithwaite’s (1989) approach to crime control.
It may help give perspective if I locate the labeling theory outlined in this book with respect to other "anti-psychiatry" approaches, as they have been called. Like the viewpoints of Goffman (1961), Laing (1967), and Szasz (1961), the theory in this book offers an alternative to the conventional psychiatric perspective. The basic difference from the other anti-psychiatry approaches is that I offer an actual theory of mental illness. That is, I propose a possible social scientific solution to the problem of defining and treating mental illness. The theory is made up of concepts that are at least partially defined, explicit causal hypotheses, and applications to real events. This theory is therefore testable, as Gove and others were able to show in the early critiques of the theory.
Although Goffman’s approach is sociologically sophisticated, it does not contain a theory of mental illness. He defines his terms only conceptually, with little attention to the problem of goodness of fit to instances. Laing’s approach is psychologically sophisticated, but involved even less conceptual development. Szasz, finally, uses no concepts; his approach is stated entirely in vernacular words. This approach makes it easy for anyone to understand, even laypersons. But it is much too narrow and simplified to use for analyzing and understanding actual cases, each of which is apt to be quite complex, like most human conduct.
Szasz makes the case, very well, that the medical model is not appropriate for most cases of what is designated to be mental illness and therefore, that the term mental illness itself is inappropriate. I agree. But in order to make my argument understandable, I have resorted to that inappropriate terminology, only because it is coin of the realm. In this book, it should be understood that every time I use the term mental illness, it should be seen as encased in quotation marks. My own terminology involves a sociological concept, as explained in Chapter 3, "residual deviance."
Szasz’s reliance on vernacular words reduces his theory almost to caricature. For example, the terminology that Szasz suggests as an alternative to "psychiatric symptoms" is "problems in living." If adapted, this usage might help to destigmatize the sufferers. But the phrase is much too broad, since it encompasses a vast realm of problems. Unrequited love, over-extension of one’s credit, and the incapacities of old age are certainly all commonly encountered problems of living, but they are not the particular types of problems that are designated as mental illness. If Szasz had used the terminology "residual problems of living" (problems which don’t have conventional names), he would have come close to my solution of the problem. In any case, a social theory requires statements of explicit hypotheses, all of which are couched in terms of conceptual and operational definitions. The labeling theory provides these, the other anti-psychiatric formulations do not.
It is my hope that this edition will provide a clear statement of a sociological approach to mental disorder, and at least some small steps toward integrating it with other approaches to the understanding and treatment of mental disorder.
1 Biological Psychiatry and Labeling Theory
Although the last five decades have seen a vast number of studies of functional mental disorder, there is as yet no substantial, verified body of knowledge in this area, comparable, say, to medical knowledge of infectious diseases. At this writing, there is no rigorous and explicit knowledge of the cause, cure, or even a coherent classification of the symptoms of functional mental disorders (such as schizophrenia, depression, anxiety disorders, etc). Such knowledge as there is, is clinical and intuitive. Clinical knowledge in psychiatry and the other mental health therapies is large and impressive, but so far has not been formulated in a way that would be subject to verification by scientific methods.
During these five decades, most research on mental illness has sought to establish three main contentions:
Etiology (causation) 1. The causes of mental illness are mainly
Classification 2. Types of mental illness can be coherently
Treatment 3. Mental illness can be treated effectively and
safely with psychoactive drugs.
My argument about these claims will be based on a highly selective review of the relevant literature. My emphasis, for the most part, is on those studies that raise questions about the validity of the biopsychiatric approach. My review is probably as unrealistically negative as the biopsychiatric literature is unrealistically positive. A balanced review is yet to be made (for a recent attempt, see Chapter 3 of Mechanic 1999).
Many people have the impression that all three of the biopsychiatric goals have been reached. Articles by journalists usually assume as much. Indeed, most of the articles published in psychiatric journals at least imply that these three goals are already established or that they will be established shortly. They are taken for granted. Certainly in psychiatric practice it is now a truism that most cases of mental illness should be treated with psychoactive drugs. Indeed, many psychiatrists argue that it is unethical not to. Their effectiveness and safety is assumed not only by the majority of psychiatrists, but also by Health Maintenance Organizations, who in insuring medical care, have come to have an enormous say in the practice of psychiatry. Needless to say, advertising by drug companies continuously brings these alleged truths before the public.
But these assumptions still have not been proven. The true picture is much more complex. In a recent editorial in the American Journal of Psychiatry, a biological psychiatrist (Tucker 1998) complained about the three goals. He argues that the system of classification developed in psychiatry (DMS-IV) does not actually fit many patients, and that it has only succeeded in distracting attention from the patient as a whole. His main objection, however, is that the syndromes outlined in DMS-IV are free standing descriptions of symptoms. Unlike diagnoses of diseases in the rest of medicine, psychiatric diagnoses still have no proven link to causes and cures. As Tucker says, making a point about both classification and causation: "All of this apparent precision [in DMS-IV] overlooks the fact that as yet, we have no identified etiological [causal] agents for psychiatric disorders" (p. 159). This particular sentence exactly explodes the biopsychiatric bubble (See also Valenstein 1998).
This article is especially noteworthy because it appears in the flagship journal of the American Psychiatric Association, the main psychiatric association in the United States, the home country of biological psychiatry. The most widely read of all psychiatric journals, until 1998 it relentlessly promoted the three-fold objectives of biological psychiatry. This direction now seems to have slightly shifted, however, suggesting that the dominance of biological psychiatry may be coming to an end.
A second article challenging the position of biological psychiatry was published in the same journal soon after the Tucker article, reviewing studies that support interpersonal causation in the origins and outcome of mental illness (Lewis 1998). Lewis proposes ten central premises of the interpersonal school of psychiatry, and reviews studies that show the effectiveness of secure adult relationships in undoing the adult consequences of destructive childhood experiences, and the role of well-functioning marriages in decreasing depression. The appearance of the editorial and the special article in the AJP that challenge fundamental tenets of biological psychiatry may signal the beginning of the end of its dominance.
Even during the years of biological dominance, there has been a steady stream of studies that raise crucial questions about each of the three major strands. The status of claims of biological causation and systematic classification have always been ambiguous. Obviously there have been significant advances in knowledge about the interaction of biological and non-biological factors in mental illness. A representative study of rates of occurrence of schizophrenia in Finnish twins can serve as an example (Tienari et al 1994). They found that the rates of schizophrenia in the "adopted-out" twin born to a schizophrenic mother was many fold greater than in the population at large, suggesting a genetic factor. But on the other hand, even though the rates were high, still most of the adopted twins with a schizophrenic mother were not diagnosed as schizophrenic, suggesting a non-genetic origin.
To confirm a genetic cause, even for only one part of those diagnosed as schizophrenic, the deficit gene would have to be isolated. Although studies of DNA report promising areas of exploration, this step has yet to occur. Like the claim of being on the threshold of a break-through in psychoanalysis earlier in the century, the claim of genetic causation seems premature (Grob 1998).
The classifications of psychiatric disorders that have been organized into the succeeding DSM versions appear to be little more than attempts to confirm current psychiatric practices, rather than empirical studies. Empirical studies usually show broad discrepancies between diagnostic categories and patient symptoms. An example is the study of symptom clusters by Strauss (1979), a widely respected research psychiatrist. He compared the actual cluster of symptoms that each of 217 first admission patients displayed with the diagnostic syndromes. He concluded that the clusters of "the vast majority [of the patients] fall between syndromes." That is to say, that the symptoms of the large majority of actual patients do not cohere the way the DSM organizes them, suggesting that, in this fundamental respect, the problems that psychiatrists treat do not seem to fit into the medical model of disease (Also see Mirowsky 1990).
Researchers from social work have published two books suggesting that the DSM classifications are determined much more by the politics of psychiatry rather than by evidence (Kirk and Kutchins 1992; Kutchins and Kirk 1997). In the first book (1992) they show that evidence which would confirm the DSM classifications is vanishingly small.
The strongest strand of the biological revolution in psychiatry has always been treatment with psychoactive drugs. In the early years of their use, these drugs were seen as ways of controlling and dispelling the symptoms of mental illness, if not as absolute cures. Especially when compared to psychological and social measures, drugs were seen as being cheap, quick, safe, and effective. There is still no question about how quick, cheap, and easy to administer the drugs are. But in the last twenty years evidence which contradicts the effectiveness and safety of psychoactive drugs has been becoming available. There are also indications that these drugs may be administered to manage or control certain categories of patients, rather than to help them.
Effectiveness of psychoactive drugs.
There are a vast number of systematic studies that seem at first glance to testify to the effectiveness of psychoactive drugs. These are almost all what is called randomized clinical trials (RCTs), carried out using the standard design for scientific experiments. A group of patients with similar diagnoses are divided randomly into two subgroups. One subgroup, the treatment group, receives the drug, the other, the control group, get an inert substance disguised as a medication, a "placebo". The design requires that the administration of the substances be "blind"; that is, neither the patients nor the doctors know which are the drugs and which placebos. If the subgroups are set up at random, and if the participants are "blind", then any change in the treatment group larger than the control group can be confidently ascribed to the effects of the drug.
The usually positive results of these studies is thought to demonstrate two points: First that psychoactive drugs are more effective than the placebos used in the control groups, and that their effectiveness is due to the correction of biological deficits in the patients. However it is important to note that even if these results are accepted at face value, the average difference in effect between the drug and the placebo group in the typical study is not large, and often short-lived, as shown in studies over time. Typically, in repeat studies done from four months to eight months after the initial one, the average advantage of the treatment group over the control group has decreased or even disappeared. Since we are dealing with averages among many patients, this is not to say that there aren’t strong positive and negative, and even no effects on individual patients. To summarize: even accepting the validity of the RCTs, most psychoactive drugs are only slightly and briefly more effective than placebos. The decreasing effectiveness over time is suggestive of a placebo effect.
In recent years there have been a sizable number of studies that challenge the standard interpretation of the RCT studies, that psychoactive drugs, in themselves, are more effective than inert substances, and that their effectiveness is due to the correction of biological deficiencies. It now appears that most RCTs are not truly blind, because most of the participants can make accurate guesses as to whether the patient is receiving a psychoactive drug. Shapiro and Shapiro (1997, Table 9.1) reviewed 27 studies that asked doctors, patients, and "raters" (outside observers) to guess who was receiving the drug.
On average, 93% of the doctors, 73% of the patients, and 67% of the raters could accurately guess the active agent. Doctors, patients, and raters can use physical effects, taste, color, texture, and dissolvability to guess. Especially for the patient, the physical effects on the body often reveal the active drugs, since many of them are powerful stimulants, sedatives, or emotion blockers. The drug companies who conduct most of the RCTs seldom try to make a close match between the drug and the placebo, because they think it is not sufficiently important to warrant investing in the complex task of precise matching. In a scholarly review of this issue Healy (1997), is also critical of the use of RCTs in evaluating the effects of anti-depressants.
In my opinion, even a careful attempt at precise matching would face an insoluble dilemma. If the placebo were precisely enough matched to the medication, then its own effects on the patient would make the results of the experiment ambiguous. I think that experimental designs that necessitate blind administration of medicine and placebo are inappropriate for human beings. Case studies are more appropriate. Although they also involve reliability problems, they are neared to surface. The RCTs hide validity and reliability problems behind the mask of hard science. For a proposal to apply the case study method to the problem of evaluating drug effects, see Jacobs and Cohen (1999).
If the great majority of the participants are not truly blind, then the validity of the entire method of research is thrown into question. The purpose of the RCT design is to rule out all explanations other than the biological effect on the patient. If most of the patients and doctors in the studies know which medications are active, the possibility arises that some or even most of the effects are psychological and/or social.
This possibility is known as "the placebo effect." It has been documented that all substances prescribed by a physician, even if they are inert, can have powerful effects on the patient (Fisher and Greenberg 1997; Harrington 1997; Shapiro and Shapiro 1997). The processes that give rise to this effect are not well understood. It is believed, however, that the social psychology of hope, both in the doctor and in the patient, plays an important role.
Even in physical illness, the loss of hope can lead to deterioration of health independently of the disease process. For example, one study of 2, 400 middle-aged men (Everson, Goldberg, and Kaplan 1996) found that hopelessness was the best predictor of death from heart disease and cancer. Six years after the initial interview, the 11% of the men with the highest level of hopelessness had died at three times the rate of the men who were hopeful. Hopelessness was the best predictor of death or illness even in those men who had no prior history of heart disease or cancer.
In mental illness, the effect of hope is probably still greater. Anything that can increase the patient’s hopefulness can be potent medicine. In understanding the effects of psychoactive drugs on doctors and patients, it is important to remember that before "the tranquilizer revolution," many psychiatrists believed that there was nothing they could do to help their patients, especially their psychotic patients. Perhaps the chief effect of these drugs, particularly the anti-psychotic ones, has been on the psychiatrists, restoring their confidence in their own competence, and therefore their hope for the patients. The doctor’s hope, quickly sensed by their patients, could increase the patient’s own hope, and improve the relationship between doctor and patient, and therefore the whole social psychology of treatment of mental illness.
Of course many, many patients are themselves convinced that they have been helped by psychoactive drugs; they feel that the drugs they were given were instrumental in controlling their psychosis, depression, or anxiety. What is the harm to them if the help they got, in most cases, was entirely due to the placebo effect? This issue brings up the question of side effects of psychoactive drugs.
Are psychoactive drugs safe?
Just as placebo effects accompany all substances prescribed by physicians, so also do side effects. It has been known for many years that some of the widely used anti-psychotic drugs (neuroleptics), such as Thorazine, cause neurological damage, even in small doses, if they are administered regularly (Cohen, 1997). It is possible that all psychoactive drugs, including the mildest tranquilizers, have potent side effects. The side effects, unlike drug effectiveness, have not received enough direct research attention. Since the actions of most psychoactive drugs are complex and not understood, patients receiving them are being experimented on.
There are now many studies that demonstrate adverse effects of psychoactive drugs in a sizeable minority of patients. Tardive dyskinesia, alluded to above, is caused by Thorazine and other similar neuroleptics. If administered for as little as three months, even in low dosages, these medications will sooner or later cause severe neurological damage, tardive dyskinesia. In this syndrome, the patient looses control over his body, leading to involuntary spasms and tics that impair motor functions. Surprisingly, although this side effect is widely known, and many new neuroleptics have been introduced which are supposed to be less likely to cause it, Thorazine and the other offending drugs are still used widely (Cohen 1997).
Anti-depressants have also been shown to have adverse side effects. One study (summarized by Ayd 1998) showed that these drugs led to profound apathy and indifference in 11% of the patients who receive the drugs. A second study (Settle 1998) reported that 20% of 207 consecutive admissions to a psychiatric hospital had psychoses caused by withdrawal from anti-depressants. Surely in physical medicine any treatment which had such severe and frequent side effects would be peremptorily suspended from use. It is no longer clear that the benefits of psychoactive drugs outweigh the costs, even though a majority of psychiatrists, and all drug companies and HMOs, have persuaded themselves that this is the case.
In my own observations of persons who take psychoactive drugs, the reactions have been variable. In mental hospitals, by the middle of the eighties, virtually all of the patients were being given psychoactive drugs. Most of the patients were receiving at least two different drugs, some as many as five. Most of the patients I interviewed complained about adverse effects, hinting that they discarded them. Some showed me how they were able to evade the drugs even if they were given them by nurses, being able to "mouth" the drugs so that they could later dispose of them.
Some of my outpatient subjects were ambivalent about their drugs. Two of them had a quite similar reaction to lithium carbonate, a mineral still widely used to control mood swings in bi-polar (manic-depressive) illness. Both reported that the mineral brought considerable relief from their mood swings, but also interfered with their mental and creative capacities. Both elected to discontinue.
On the other hand, a few of the hospital patients, and a majority of the people I knew as outpatients, told me that they were undoubtedly helped by their drugs, often spectacularly. In questioning them closely about drug effects, I usually found that these subjects were convinced to the point that they were impatient with my detailed questions. Some reminded me of persons who had had a religious conversion. They sang the praises of their drugs, and were not cooperative in responding to questions.
The psychiatrist Aaron Lazare (1889) found that many patients in the outpatient clinic he directed requested tranquilizers, even in cases when the psychiatrist thought other treatments were indicated. In response, Lazare developed a protocol he called "the negotiated approach to outpatient treatment," and trained his staff to use it. First the psychiatrist elicits a request from the patient, with a choice of 14 categories: advice, confession, succorance, ventilation, and so on. If the patient requested drugs, the psychiatrists were taught to give the patients brief demonstrations of alternative treatments, such as psychotherapy. Using this method, Lazare’s clinic managed to reduce the number of patients on drugs to a level far lower than the average.
There is one further problem connected with the biological approach, the way it is used with vulnerable populations. It seems likely that it is frequently being used to control or manage children, confined aged persons, and women, rather than to help them. It is clear that the drug Ritalin is being used widely to control children that teachers find difficult to manage (Breggin 1998, Diller 1998; DeGrandpre 1999; Walker 1998 ). Even a physician who prescribes their use admits that they are vastly over-used (Diller 1998). Although not condemning the cautious use of Ritalin, Diller, like Breggin, DeGrandpre, and Walker, proposes that there is an epidemic of indiscriminate use for problems that are social or psychological rather than biological.
There is also scattered evidence that psychoactive drugs are administered indiscriminately to a majority of the elderly who are confined in convalescent and board and care homes. "… neuroleptic medications are used in 39% to 51% of elderly institutionalized patients" (Lancetot, et al, 1998). These figures refer only to anti-psychotic drugs. If anti-depressants and other tranquilizers were included, the figures would be much higher. It may be that psychoactive drugs are being used as chemical straitjackets for a large majority of the confined elderly.
There have be a sizeable number of books and articles which protest the way in which psychiatric diagnosis and treatment systematically discriminates against women (For reviews, see Brown 1994; Lerman 1996; Tavris 1992). It would appear that what would likely be called symptoms of mental illness if they occur in women are apt to be ignored when they occur in men. Since the vast majority of psychiatrists, until quite recently, have been men, feminist commentators argue male psychiatrists have usually discriminated against women in their diagnoses and treatment. They also argue that the DSM classification series has discriminated against women. For example, sexual behavior that would probably be ignored in men has been classed as psychopathy or hypersexuality in women:
"…the concern over female autonomy that was implicit in the category of hypersexuality helps explain why psychiatrists considered failure to engage in heterosexual courtship ----whether simple lack of interest or overtly lesbian behavior ----just as psychopathic as a woman’s too vigorous exercise of her seductive powers (Lunbeck 1994, p. 522)".
Although Lunbeck’s comment concerns diagnostic practices earlier in this century at the Boston Psychopathic Hospital, evidence provided by Brown, Lerman, and Tavris suggest that it is still relevant to current practices.
Challenging the rule of biopsychiatry
Biopsychiatry so dominates the whole field of mental illness that it is difficult to view the field from a different perspective. It is not easy to locate descriptions of practice that do not assume the three central principles of classification, causation, and treatment described above. To give an alternative view, I call upon a report by a psychiatrist who substituted for a vacationing regular at a managed care mental health clinic. This psychiatrist has asked that he not be identified for fear of retaliation.
"The clinic was privately run, but it had the state contract to provide the local community mental health. I chose not to speak openly about my views, but to lay low and keep quiet… I did manage to lower the dose or discontinue the medications on most of the patients I saw. I was also able to get the court-ordered treatment rescinded on one patient, so all in all I was able to do some good…
Here’s what I learned: The whole mental health system seems to be relying almost exclusively on medications. If a patient requests medications, he is given it freely. If he requests any kind of counseling or therapy, he has to present his request before a review panel that will in most cases deny the request. When a patient was not doing well, everyone looked to me immediately to "adjust his medications." If the patient was already adequately medicated, then the assumption was that the patient must not be "compliant." No one ever seemed to consider the possibility that the medicines may not work, even if taken. Nearly every patient I saw was on multiple medications.
The majority of patients on Lithium and Depakote were not being adequately monitored with the required blood tests (I diagnosed 4 cases of lithium-induced renal impairment that should have been detected long before). Tardive Dyskinesia was very prevalent but frequently undiagnosed or misdiagnosed. Even in diagnosed TD, the offending agent was not discontinued, except in a few cases. Most patients had no idea what medicines they were taking or why. They take the medicine because everyone wants them to, or in some cases because their continued SSI, housing, and other benefits depended on it. The whole system is infantilizing. Those people who take well to being infantilized, thrived in it (i.e., they became fully infantile). Those who didn’t were considered difficult.
I was hailed by the clinic staff and by many patients as a good psychiatrist, mostly because I was the first psychiatrist they had seen who bothered to talk with patients about their real problems. Apparently all other psychiatrists focus exclusively on medications and "symptoms." The progress note and psych eval forms they gave me to complete were fill-in-the-blank checklists that were exclusively symptom-oriented. If I wanted to note any sort of psychosocial issue (like the patient going through a divorce, etc) I had to write it in the margin! I thought that pretty much said it all. I did a lot of scribbling in the margins in hopes that maybe someone would read it and be inspired to think of the person as a person, and not just as a set of symptoms.
Although this particular observation, based only on one clinic, may not be universally relevant, it is alarming enough to warrant at least some skepticism about biopsychiatry. It could well be the promised breakthrough, or it could also be a mere house of cards. It is too early to tell.
Given the lack of substantial knowledge of drug actions and effects, an attitude of patient study and observation would seem to be fitting for biopsychiatry at this time. All too often, however, mere hype is hidden by
terminology. One example is the naming of the anti-depressant drugs called SSRIs (Seratonin re-uptake inhibitors), like Prozac, Zoloft and other similar drugs. A more modest procedure for naming would be to use the chemical class these drugs belong to, because the name SSRI prejudges the issue. Although there is substantial evidence that the amount of seratonin (a neurotransmitter) available to the brain is increased by these drugs, it is also known that they have many other complex effects, none of which are understood. It is conceivable that the positive drug effects are not due to seratonin, or at least not solely, but to one or more of the other effects (Thase and Kupfer 1996).
The emotional/relational world
Given the over-all picture of the lack of proof of genetic causation, the chaos of diagnosis, the small average efficacy and dangerous side-effects of psychoactive drugs, and their abuse in vulnerable populations, why hasn’t the biological approach been overthrown? The economics of drug use supplies part of the answer. It has been extremely profitable for drug companies to exaggerate the efficacy of psychoactive drugs, and to play down their brief effectiveness and destructive side effects (For documentation of the drug companies’ role in suppressing negative evidence, see Breggin 1991; Ross and Pam 1995; and Healy 1997). It has also been profitable to the HMO’s and to many of the psychiatrists who administer them.
The main alternative to drugs is psychotherapy, which is lengthy and extremely costly in comparison, and whose outcome is uncertain. HM0s much prefer paying fifty to a hundred dollars a month for medications than the at least 500 dollars a month that four sessions of psychotherapy would cost. Similarly, the psychiatrist who dispenses drugs can schedule four patients an hour, rather than taking a whole hour for each psychotherapy patient. Being a psychotherapist rather than a pill prescriber also takes more skill, considerably more patience, and exerts more emotional wear and tear on the therapist. Identifying the emotional and relational tangles in a patient’s life is not an easy task, requiring experience, patience, and self-confidence. Finally, psychoactive drugs give psychiatrists a competitive edge over other professionals who treat mental disorder, since only psychiatrists can prescribe them.
But independently of these incentives, there is also a powerful demand for drugs from patients and from their families. Drug treatment upholds the social and emotional status quo; individual and group psychotherapy can threaten it. Psychiatric approaches to the causes and treatment of mental disorder that focus on biology have been embraced wholeheartedly by the families of mental patients who support the National Alliance for the Mentally Ill (NAMI) To them, biopsychiatry seems to dismiss the possibility of familial causes and changes in the family system that might be required by social and psychological approaches. These families have bitterly rejected the idea that family relationships may be a cause of their relatives’ mental disorder. Biological psychiatry, as they interpret it, seems to relieve them of dealing with shame and guilt, and indeed, from any concern with their own behavior, emotions and relationships. It leaves their family systems, no matter how slightly or extremely dysfunctional, inviolate.
Like the dark side of the moon, the emotional/relational aspects of Western civilization are usually hidden from view. Western societies are highly oriented toward individualism and individual achievement (rather than towards groups and toward tradition, as in Asian and other traditional societies). Perhaps the clearest exposition of this doctrine was voiced by the American philosopher Emerson, in his philosophy of self-reliance. In one of his many peans to the individual, he said: "When my genius calls, I have no father or mother, no brothers or sisters." This idea is exactly opposite to the ruling idea in traditional societies, that NOTHING comes before family, clan, or nation.
Unwittingly, Emerson’s idea has become one of the main driving forces in Western societies. It prepares children for individual careers, enabling them to be social and geographically mobile so that they can avail themselves of opportunities for achievement, no matter at what personal and interpersonal cost. It has been one of the main forces leading to the suppression of emotions and ignoring personal relationships. One’s feelings and the quality of one’s personal relationships do not show up on résumé’s; they are dispensable. The relational world and its accompanying emotions have become virtually invisible in the Western middle-class world.
A classic example of the role of emotional/relational tangles in generating psychiatric symptoms was provided by a psychiatrist/sociologist team (Stanton and Schwartz 1954) in their study of patients in a mental hospital. Using case histories of symptom flare-ups, they demonstrated that each and every one was due to events in the patients’ social environment. The feature common to all of their cases, they found, was covert disagreement among the staff about the patient. To unearth the actual cause of the flare-up took, in each case, patient and sometimes lengthy investigations. Even then, in the pre-tranquilizer era, there was considerable pressure to attribute the flare-up to the patient’s illness, and to treat it with medication. The identification and correction of emotional /relational tangles is not a simple task, especially since it sometimes results in collisions with the egos of the participants, and the emotional/relational status quo in the organization or family.
Another example of social/emotional causation of symptom flare-up can be found in Retzinger’s (1989) microanalysis of a psychiatric examination of a woman who had been previously diagnosed as schizophrenic. Taken from a widely used textbook on the initial psychiatric examination (Gill, et al., 1954), the flare-up of the patient’s delusions is usually interpreted as an unpredictable outcome of the patient’s illness. But Retzinger’s close examination of the transcript tells a different story. She shows that the psychiatrist’s (Fritz Redlich) manner initially was so warm and sympathetic that the patient responded to him in a patently sane and human way. The turning point comes when she notices that he has been glancing at the clock. Apparently threatened by being caught out by a supposedly insane patient, or perhaps worried about who was in control, Redlich’s manner abruptly shifts. Without warning, he changes from a friend to a relentless diagnostician. He repeatedly probes and leads, trying to unearth the delusions reported in her record, to the point that she relapses into a delusional state. Retzinger calls Redlich’s maneuver "reverting to technique", a subtle labeling and rejecting of the patient as a person. In this instance, the psychiatrist unwittingly shamed the patient into a delusional state.
The labeling that goes on in "Rhoda’s" family (Chapter 10 in this book) is also subtle. In the dialogue between her and her mother that Rhoda reports in the therapy session, the mother never says directly that Rhoda is mentally ill, but she repeatedly implies that Rhoda is not a responsible person. Rhoda must understand this implication, because her emotional reactions are intense each time it occurs. The transcript on which this chapter is based is taken from another well-known text, an early microanalysis of a therapy session (Labov and Fanshel 1977).
Labov and Fanshel’s reaction to their own analysis illustrates the elusiveness of the emotional /relational world in our civilization. At the end of the book, they note that if their analysis of the family dialogue reported by Rhoda is to be believed, then conflict is perpetual in that family: every line bristles with covert hostility, rejection, or withdrawal. But this idea troubles the authors, because it also clear from the dialogue that Rhoda and her mother are both completely unaware of their emotional conflict; they recognize only physical violence (Rhoda is anorexic). Labov and Fanshel raise an astounding question: how could there be conflict if the participants are unaware of it? Opting to believe the participants rather than their own data, Labov and Fanshel disown their work, the emotional/relational world they themselves uncovered.
Biological approaches to mental illness support and help perpetuate the hiding of the emotional/relational world. This is a Durkheimian idea that I will discuss further later in this book. Preserving the inviolability, the sanctity of our avoidance of emotions and relationships can help explain the intensity of the societal reaction to mental illness. Biological psychiatry, in its crude popular form, is a collective representation that serves to maintain the emotional/relational scheme of things in our society.
Gove’s Critique of the Labeling Theory of Mental Illness
In the 70’s and early eighties, Walter Gove published several articles and two highly influential critiques (1980; 1982) of labeling theory. He proposed in these critiques that the evidence was so overwhelmingly negative that the theory should be abandoned. At least in mainstream studies in sociology and in related disciplines, his recommendation was nearly carried out. As a result of both the ascent of biological psychiatry and Gove’s and other critiques, the great majority of researchers in social and medical science have virtually dismissed labeling theory as a fad of the sixties and seventies.
Since Gove’s critique has been so influential, I will critique it in turn, in light of the evidence since the time that it was published. I cannot much criticize his review of the evidence at the time that he wrote. With some exceptions, the studies that sought to apply the theory found little or no support for it, just as he said. A clear and explicit general theory that is testable is a rarity in the social sciences. The survival of general theories like Marx and Freud’s are due, in least in part, to their vagueness. Quantitative researchers, whose forte is entirely given over to testing hypotheses, rather than generating them, fell up on labeling theory ravenously. There were encouraged also by the hubris of the original theory, which overstated the importance of labeling.
By now, however, the situation has changed. In the last twenty years, there has been a steady stream of studies that give a much more mixed picture. On the one hand, there are still plentiful studies that ignore labeling hypotheses, reject them on a conceptual basis, or, in some cases, once more find negative evidence. On the other hand, there are by this time a large number of studies that consistently report labeling effects. The best-organized series has been conducted by Bruce Link and his colleagues. For the period 1980 to 1990, Link and Cullen (1990) report eight of Link and his colleagues’ own published studies, as well as those of others; they all show labeling effects in mental illness. More recent studies (Link, et al 1991; Link et al 1992; Link et al 1997) continue in the same vein.
To be sure, the continuing evidence for the labeling theory of mental illness is still sparse and mixed; a mixture of positive and negative findings. However, we now know that the evidence relevant to biological psychiatry is also mixed. As already indicated, there are now many studies which at least raise questions about the validity of genetic causation, the effectiveness and safety of psychoactive drugs, and the reliability of diagnostic classifications. There are also reasons to doubt the validity of the many studies of effectiveness and safety of drugs that were produced or sponsored by drug companies (for documentation of the exaggeration of positive evidence and suppression of negative evidence, see Breggin 1991; 1997).
Even acknowledging the initial spate of studies which failed to support the labeling theory of mental illness, Gove’s recommendation that it be abandoned also arose out of the unfavorable comparison he made between labeling and psychiatric theory. Although his assessment of the evidence available at the time of his critique was mostly sound, his assessment of the validity of the psychiatric approach was not. He far over-rated the coherence of diagnosis, the effectiveness and safety of drugs, and indeed, the validity of the entire psychiatric approach. Given what we now know, Gove’s view of psychiatry was naïve. For this reason, it seems to me that the labeling theory of mental illness is still in the hunt. Of course I am not suggesting that the other theories should be replaced by labeling theory, but only that mental illness, and indeed all human behavior, is still pretty much a mystery; competition between viable theories is still needed. In the next chapter I will discuss social systems and the relational/emotional world, steps toward a consilient (Wilson 1998) approach to the problem of mental illness.