PREFACE (The preface from the 1999 addition is in Times Roman
Material added to the 1999 edition is in this [Arial] font.)
editor of this re-issue has asked me to write a new preface. As with the 1999
edition itself, I have revised the preface mainly by addition, since the
original still stands.
book concerns the relationship between what is called mental illness in our
society and the larger context in which it occurs. If the science of “ mental
health and mental illness” is to advance, it may need to consider not only the
microworld of biology, but many larger worlds, notably, emotions, relationships
and social systems. The individual self is not made up only of physical
systems, but also emotional and relational ones, and is deeply and intimately
involved in social systems. Perhaps we need to conceptualize the basic problems
in this area in a new way that would integrate individual and social systems.
Labeling theory, which concerns the social system, can be integrated with a
theory of emotional/relational and social dynamics that occur within, between
and around the self.
simplify her task, when God created an onion, she probably started with the
inner core working outward. However she could have also started with the outer
skin, working inward. Even if you are not God, it doesn’t seem to matter which
way you start, as long as you realize an onion is not just the inner core, nor
is it only the outer skin. We should describe each of these layers, and at
least sketch out theories that relate them one to another.
has so far convinced the public that the innermost core of the self, an
individual physical system, is all that matters. The labeling theory of mental
disorder (Scheff 1966; 1983; 1999) proposed the opposite trope (metaphor), that
the societal reaction, one of the outer layers of the onion, was more
important. But the truth of the matter is that most of the onion, the great
bulk, is neither core nor skin. We need to move beyond both of these tropes,
into the layers and layers that make up a complex phenomenon.
latter chapters of this book apply new concepts to specific cases, indeed to
actual dialogue within cases. For example, Chapter 9 provides a specific moment
in a psychotherapy session that implies an intermediate layer, the complex
family system dynamics between a mother and her two daughters that lead to the
labeling of one of the daughters within the family.
Szasz is one of the earliest debunkers of the idea that psychiatry should be
based solely in biology. He is in the great tradition of rebels, those who have
attempted to overthrow the status quo. In this light, Szasz has taken what
seems to be an absolutely necessary first step, challenging the trope of
"mental illness." If he hadn’t existed, we would have had to invent
someone like him.
Szasz has not offered any sufficiently detailed alternatives. Art and science,
as William Blake urged, needs to deal with "minute particulars."
Perhaps the next step is to establish a model alternative to the myth of mental
illness, one that encompasses the minute particulars of social, psychological,
and biological reality. The later chapters in this book concern one such
alternative, a theory of the emotional/relational world as it has been
described in Retzinger (1991), Scheff and Retzinger (1991) and Scheff (1994;
grip that established metaphors and myths have even on science has been nicely
caught by the philosopher Quine (1979):
The neatly worked inner stretches of science are an open
space in the tropical jungle, created by clearing tropes [metaphors] away"
(1979, p. 160.
is to say, it often happens that before science can be applied, an
obstructive metaphor has to be overthrown. The history of the physical sciences
is full of examples. For example, progress in the astronomy of planetary motion
was delayed for over a century because of the trope that the earth was the
center of the universe. This idea is a correlate of universal ethnocentrism:
the conceit that we human beings are the center and purpose of the cosmos.
like everyone else, took for granted that planets circled around the earth. In
the l6th century, Brahe had made a very accurate charting of the transit of
Venus. But he could not plot the shape of the orbit because he assumed Venus
was orbiting around the earth. Kepler, who inherited and added to the data
after Brahe’s death, was equally puzzled for many years.
idea of a logocentric universe was so ingrained that Kepler hit upon the
solution only inadvertently. In a largely irrelevant burst of creativity, he
devised a geometric model of the planetary orbits based on transparent solids
representing cubes, spheres, and polyhedrons. The model was absurd except for
one feature; in his playful excitement, Kepler had inadvertently placed the
sun, rather than the earth, at the center. But the "error" made him
aware of a new way to compute the orbit.
Einstein began work on the theory of relativity with a joke concerning persons
passing each other on trains, trying to determine their speed relative to each
other. He realized intuitively that this situation challenged the ruling trope
that time and motion were absolute. Although he had a doctorate in physics,
Einstein knew little mathematics. Apparently he had found it boring, and missed
or slept through many of his classes. He had to get help to put his anti-trope
into mathematical form. Like Kepler, he was a trope-clearer.
Kepler and Einstein, Szasz attacked a ruling metaphor in Western society. His
target is the idea of mental illness, and its planetary system of concepts
(symptoms, patients, hospitals, drugs as medicine, etc.). He was the first
psychiatrist to forcefully and repeatedly claim that these concepts fit reality
poorly. Since our society still accepts the myth of mental illness, Szasz’s
attack is ongoing.
Szasz’s challenge was the work of others in the anti-psychiatry movement:
Goffman, Laing, my own labeling studies, and many others. These studies, like
Szasz’s, were a step forward. But they were not sufficiently detailed, on the
one hand, nor theoretically framed, on the other, to get to the core of the
problem. Neither Szasz nor Goffman or Laing sought the equivalent of the
mathematical formatting that enabled Kepler and Einstein to replace an obsolete
view with one that better fit reality.
Although Goffman’s approach is sociologically sophisticated, it does not
contain a theory of mental illness. He defines his terms conceptually at most,
without attention to the problem of goodness of fit to actual instances.
Laing’s work 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 real cases, each of which is apt to be quite
complex, like most human conduct.
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 de-stigmatize the sufferers. But the phrase
is much too broad a tool for understanding, since it encompasses an impossibly
vast realm of problems. Unrequited love, over-extension of one’s credit, and
the physical incapacities of old age are certainly all commonly encountered
problems of living, but they are not the particular types of problems that are
usually 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
own 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. Labeling theory was a step in this direction, but it
was too narrow to grasp the intricacies of emotion and relationship that generate
functional and dysfunctional behavior.
One obvious limitation of labeling theory was that it dealt only with the
societal reaction to residual deviance, but not with the origins of that
deviance. It simply bypassed the question of the biological and/or
psychological causes of symptoms. In some ways, this orientation was a
strength. In some cases of what is labeled as mental illness, there are no
symptoms. When I was observing mental hospitals in the 60’s in the US, England,
and Italy, many of the patients were unhoused seniors who wintered in mental
hospitals. In Stockton State Hospital in 1959, I found that there were many
patients with no detectable symptoms who were being used as unpaid laborers.
The vast laundry facility was run almost entirely by these patients, most of
whom were Chinese immigrants to the US who had never learned English. Perhaps
symptoms had led to their original hospitalization. But, in any case, symptoms
no longer played a role in their "mental illness."
But the single focus of labeling theory on societal reaction is also a
weakness, a sin of omission. If human beings are going to live in peace
together, we need to better understand the origins of symptoms such as
depression, delusion, compulsion and obsession, for example. These symptoms can
be found not only in mental patients, but scattered throughout whole societies,
even among ruling elites. They are an important aspect of the human condition,
and need to be further investigated. Lemert’s study (1962) of paranoia by
persons in high positions in organizations provides a model.
Closer to the dialogue that is to be analyzed in this paper, labeling theory
had a further weakness: it focused entirely on the formal, official societal
reaction to residual deviance. As the dialogue excerpted from Rhoda’s
psychotherapy session suggests, there is also an informal process of labeling
that takes place within families, before they has been any suggestion of a
formal reaction from officialdom. Informal labeling in the family, it would
seem, is the next layer down of the onion, right beneath its outermost layer,
the formal societal reaction. In his extraordinary paper on the growth of
paranoid symptoms in an individual inside of an organization, Lemert (1962)
provided an earlier description of the process of informal labeling and its
effects. But labeling is but one of many processes that occur within the
The Emotional/Relational World
This essay is a proposal for creating a dynamic model of the
emotional/relational world, a world that is mostly disguised and ignored in
Western societies. A recent cartoon in the New Yorker is apropos. A male
client, lying on the couch, is saying to the analyst: "Look, call it
denial it you like, but I think what goes on in my personal life is none of my
own damn business!" Like much of the best humor, this caption contains a
core of truth. We are all trained to ignore the emotional/relational world.
My approach requires integration between the social sciences in general, and
between sociology and psychology in particular. It points towards a theory that
could lead to the empirical study of actual social relationships, the core
subject of all of the social sciences and a crucial subject for the mental
health professions. With emotions and relationships routinely disguised and
ignored in Western societies, social sciences that also ignore it serve a
conservative function, helping to preserve the status quo in the
Goffman (All of his books, but especially 1959; 1959a; 1963; 1963a; 1967)
was the poet and prophet of the emotional/relational world. But his work is
only a beginning, since it doesn’t involve an explicit theory, method, or
systematic evidence. Another problem concerns his treatment of emotions. Compared
to most social science descriptions, his are three dimensional, dealing not
only with thought and behavior, but also with feeling (Scheff 2000a).
But with the exception of one essay focused on embarrassment (1967), he
portrayed emotions only by implication. There is considerable embarrassment,
shame, humiliation and disgust implied in his representations, but it is seldom
make explicit. In this respect, his methods of dealing with emotion are similar
to the usual treatment of emotion in Western societies, disguising or
On the other hand, there are fruitful studies that go much deeper into the
minute particulars of human relationships, revealing whole new realms of
information about the filigree of human conduct. One such study, by Labov and
Fanshel (1977), two linguists, provides the basis for Chapter 9. They conducted
an exhaustive microanalysis of the first 15 minutes of a psychotherapy session.
They analyzed not only what was said but also how it was said, interpreting both words and manner (the
paralanguage). They based their interpretations upon microscopic details of
paralanguage, such as pitch and loudness contours. Words and paralanguage are
used to infer inner states: intentions, feelings, and meanings.
With such attention to detail, Labov and Fanshel were able to convey
unstated implications. Their report
is evocative; one forms vivid pictures of patient and therapist and of their
relationship. One can also infer aspects of the relationship between Rhoda and
her family, since Rhoda reports family dialogues. Labov and Fanshel showed that
the dispute style in Rhoda’s family is indirect: conflict is generated by
nonverbal means and by implication.
Indirect inferences, from a dialogue that is only reported, are made in
order to construct a causal model. Obviously, in future research they will need
to be validated by observations of actual family dialogue. It is reassuring,
however, to find that many aspects of her own behavior that Rhoda reports as
occurring in the dialogues with her family are directly observable in her
dialogue with the therapist. For example, the absence of greeting, and Rhoda’s
covert aggression in the dialogue she reports with her aunt can be observed
directly in the session itself (not included in chapter 9 but discussed in
The limitation of this and similar language based studies is the opposite of
that of the work of Szasz, Goffman, etc. Where their work was largely
theoretical, the linguists, working inductively, had too little. In particular,
they had no theory of emotion and relationship dynamics that would help them
interpret the family conflict they reported. Here I will show how a theory of
these dynamics might be developed from close examination of dialogue.
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
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. In-between.” Contrary to the song, we must begin to mess with Mr. In-between.
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 have considerable thought to 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 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. In-between.
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, by biological psychiatry. 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 substantiated. These matters are too complex to deal with briefly, so will
be raised in the first chapter.
A second reason for the
declining interest in the theory were various critiques proposing that since
the theory was not much substantiated by empirical studies, it should be
abandoned. The most important of these critiques was that of Gove (1980; 1982)
in two volumes on labeling theory. 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. 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 my 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.
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 in 1999, I revised mainly by addition rather than by
making large changes in the original text (Chapters 3-5). A new Chapter 1 took 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.
In the 1999 edition I resisted the temptation to make large
changes in the text outlining the theory that
was published in 1966 because it is still 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 the labeling
theory of mental illness.
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 in what turns out
to be a small proportion of the cases. 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
Since the 1999 edition was
published, there has been a strong trend in objective studies of the effects of
psychoactive drugs. First let me clarify what is meant by “objective” studies.
By now (2005) it has become quite clear that most of the clinical trials had
been financed by drug companies and that this circumstance compromised the
findings. These studies departed from objectivity in many ways. For brevity,
only two will be mentioned here. First, it is now obvious that in virtually all
of the studies, in order to get funding, the researchers had given control over
publication to the funding companies. What happened was that they simply did
not allow negative or insignificant results to be published.
A second serious bias was testing only short-term effects,
typically one month. Since drug companies did not favor testing effects over
longer terms, few were carried out. But all the findings of these few show the
same trend, a rapid decrease in effectiveness over the longer term. By one year
virtually all drug effectiveness has disappeared. These findings strongly
suggest that most drug response is almost entirely placebo effect.
the years, there have been many objective (not funded and controlled by drug
companies) studies suggesting that the effect of psychiatric drugs is largely
placebo. For example, Kirsch, et al, (2002) analyzed the FDA database of 47
placebo-controlled short-term clinical trials involving the six most widely
prescribed antidepressants approved between 1987 and 1999. These included
"file drawer" studies, i.e., trials that failed but were never
What Kirsch and his colleagues found was that 80 percent of
the medication response in the combined drug groups was duplicated in the
placebo groups, and that the mean difference between the drug and placebo
effects was "clinically
insignificant" Other objective (non-drug funded) studies have been
published showing similar results for most of the psychoactive drug types.
(There are also 9 commentaries accompanying the Kirsch et al article, mostly
favorable.) This study would seem to supply a much more accurate picture of
drug effectiveness because it includes the “file drawer” results that are
rarely tapped in published results. Similarly, the studies of long-term effects
(one year or more) also need to be included, since the picture they provide is
quite different from studies of short-term (typically one month) 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.
To illustrate one of the new
directions advocated here, I will give one last example of concept development.
The field of social work has been showing an interest in extending psychiatric
diagnoses to include social dimensions, in addition to individual ones. Karls
and his associates (1994) have been attempting to modify the Diagnostic and
Statistical Manual (DSM), the bible of practicing psychiatrists, by adding
social dimensions that have never been included in the DSM.
The PIE system proposed by
Karls et al implies two social systems in the DSM: the subject’s system of social roles (family, work, and
other interpersonal roles.) and any of six larger social systems (economic,
educational, etc) in which he or she is involved. This initiative seems to be a
step in the right direction, toward overcoming the individualistic bias in the
DSM. However, the Karls proposal still seems to focus on individuals, rather
than considering the new dimensions to be independent aspects of the situation
in which diagnosis occurs.
A more radical break with the
labeling aspects of the DSM would be to establish the role and social system
dimensions as independent axes, so that what is being classified is not only
the individual, but the context. The new DSM might then have only two major
axes, one individual, one social and situational:
I Individual: Physical and
II Social: family,
neighborhood, community and societal dimensions.
One outcome of such a system
would be a move toward classifying functional and dysfunctional families,
neighborhoods, communities, and nations.
For example, a school environment in which the strong get away with
bullying the weak could be rated as dysfunctional independently of the individual
being diagnosed. Similarly, any or all
of the social systems that foster racism, sexism, homophobia, blind
nationalism, etc. could also be rated as dysfunctional.
Such a scheme would raise
conceptual and research issues not usually addressed. For example, the whole
problem of how individuals can be functional even though involved in
dysfunctional interpersonal and/or social systems is only hinted at in current
discussions of “resilience.” The classification of solely individual
dysfunction leads to the neglect to this kind of question. A whole new system
of diagnosis is needed that integrates the DSM with interpersonal and social
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.
Karls, James, and Karin Wandrei
(Editors). 1994. Person-in Environment System: The PIE Classification System
for Social Functioning Problems. Washington, DC: National Association of
Social Workers Press.
Kirsch, Irving, Thomas Moore,
Alan Scoboria, and Sarah Nicholls. 2002. The Emperor's New Drugs: An Analysis
of Antidepressant Medication Data Submitted to the U.S. Food and Drug
Administration. Prevention and Treatment. 5 (July), 1-11.