In 1965, Thomas J. Scheff proposed a labeling theory of mental illness in his ground breaking work "Being Mentally Ill." It is the epitome of a labeling theory as it incorporates many elements of the labeling perspective. He challenges conventional beliefs about mental illness and proposes a sociological model of mental illness in contrast to the traditionally accepted medical model of mental illness.
His theory: (a) questions the objective reality of mental illness and puts in its place the conception that "mental illness" is both a social construction and a social role in society, (b) explores the question of why persons get labeled as mentally ill and concludes they are deviants who violate residual rules, and (c) examines the consequences of being labeled as mentally ill which frequently results in career deviance.
He asserts mental illness is not a disease but a social role. "Residual deviance" rather than mental illness is the reason why people get labeled as mentally ill. Residual deviance is the violation of norms about which consensus is so complete that people regard non-conformity as unnatural and thus a manifestation of mental illness. Being labeled mentally ill then leads to secondary deviance entrenching the unacceptable behavior and launching and locking the individual into a career of deviance. The book is organized into 9 propositions:
1. Residual deviance arises from fundamentally diverse sources.
2. Relative to the rate of treated mental illness, the rate of unrecorded
residual deviance is extremely high.
3. Most residual deviance is "denied" and is transitory.
4. Stereotyped imagery of mental disorder is learned in early childhood.
5. The stereotypes of insanity are continually reaffirmed, inadvertently,
in ordinary social interactions.
6. Labeled deviants may be rewarded for playing the stereotyped deviant role.
7. Labeled deviants are punished when they attempt to return to the conventional role.
8. In the crisis occurring when a primary deviant is publicly labeled, the deviant is
highly suggestible and may accept the proffered role of the insane as the
9. Among residual deviants, labeling is the single most important cause of careers
of residual deviance. Scheff presents an alternative explanation of unusual or bizarre behavior, which in our society is usually interpreted as a manifestation of an underlying mental illness. Both Faris' and Dunham's as well as Hollingshead's and Redlich's earlier studies assumed the existence and reality of mental illness. In addition, they assumed and accepted the validity of the psychiatric diagnosis of persons uncritically. If persons were committed to a state hospital or had been diagnosed as mentally ill by a mental health practioner, then they must, in fact, have been mentally ill. Scheff calls such studies into question and offers an alternative explanation of the behavior subsumed under the rubric of mental illness.
"Mental illness" is examined in a new light, from a labeling perspective, which views placement into the deviant role (the role of being mentally ill) as the most likely cause of persistent aberrant behavior. There are three aspects to his theory:
I. "Mental Illness" does not exist.
According to Scheff, there is no such thing as mental illness and it does not exist in some objective way in the real world as does cancer or other forms of physical illness. There is no actual physical reality that corresponds to a mental illness, it is a social construction.
A. There is no agreed on definition of mental illness:
Whereas both Faris-Dunham and Hollingshead-Redlich accepted the validity of the psychiatric diagnosis of the patient, Scheff questions the very existence of mental illness. He argues, the term has no precise meaning or referent and lacks scientific validity. Ten different psychiatrists will come up with ten different definitions of mental illness because there is no objective reality to this term. Furthermore, they will also be unlikely to agree on even the diagnosis of a particular individual. Mental illness is a "waste basket" category that has no agreed upon meaning. Many diverse behaviors are lumped together that have little in common with one another. Scheff's first proposition states residual deviance (what comes to be regarded as mental illness) has diverse causes ranging from biological and psychological abnormalities, cultural differences, stress, drugs or alcohol, to volition behavior, etc. Yet we lump these diverse behaviors which have so many different causes under a common heading called mental illness as if they were all caused by some underlying disease when, in fact, they have very little in common. Labeling them as "illness" prejudges the causes of the very diverse behaviors. By labeling them in this fashion, it gives the illusion we understand their origins. However, there is no substance or commonly shared meaning to the term of mental illness.
Yet people do sometimes act strangely, and isn't this proof of mental illness? The assumption that mental illness exists and is the cause of the aberrant behavior has also been questioned within psychiatry by Thomas Szaz (1961) in "The Myth of Mental Illness." He suggests there is not an underlying psychopathology or disease that causes most unusual behavior. Individuals develop "problems in living" that results in unacceptable behavior. "Behavior modification," a school in psychology, takes a similar position and asserts there is no underlying illness in most forms of aberrant behavior. Individuals have learned maladaptive behavior, which gets them into difficulty.
For example, a child who acts disruptively in order to gain attention from the teacher, can wind up in the principal's office, and ultimately be expelled. A psychiatric conclusion can be drawn that the child needs treatment for an underlying disorder that causes the disruptive behavior. Whereas, a behaviorist might suggest that the child engages in disruptive behavior to gain attention and the teacher could give the child attention before they act out, and then the disruptive behavior would not be necessary. Psychiatric treatment would be unnecessary. The unwanted behavior will extinguish through behavior modification techniques including desensitization, de-conditioning, and relearning more appropriate responses to those situations.
The Medical Model: Scheff, Szaz, and Behavior Modification call into question the traditional "medical model" behavior is believed to be a "symptom" of an underlying "disease" which requires medical "treatment." The medical model invokes imagery of "patients" who are "sick" with an "illness" that requires "treatment" by "physicians" "nurses" or other medical staff, sometimes in a "hospital" with "medications" like drugs or medical interventions such as psychosurgery, shock treatment, or psychotherapy. These elements taken together represent a mind-set or model, a medical model, which makes sense out of the unusual behavior and proscribes a course of action to deal it.
Scheff proposes an alternative, a sociological model of mental illness, and introduces the concept of residual deviance, labeling, social role, socialization, role freezing and deviant career to explain the same events.
B. Cultural Relativism of mental illness:
Additional support for the position mental illness has no objective properties but is subjectively problematic, is that mental illness is culturally relative. What is regarded as mental illness in one society may not be viewed as illness in another society or even in that same society at different point in time. Physical illness has objective properties; cancer is the same in whatever society it is found. But mental illness has no objective properties that are universally regarded as insanity by every culture. What is illness is determined by a particular society's perspective. What we regard as delusions and condemn, other societies may regard as visions, which people seek to experience. Mental illness like beauty is very much in the eye of the beholder. Variations also exist within societies across class, ethnic groups, gender, etc.
C. “Mental illness” is invoked to explain puzzling behavior. The concept of mental illness is a cultural way of explaining behavior that is not easily understood or puzzling within a particular culture's framework. All societies have rhetorics of motives that are culturally accepted explanations for behavior. Scheff asserts the concept of mental illness is used to explain behavior not understood in ordinary terms in that society. It is similar to the "phylogistin" theory, a non-existent element in ancient chemistry, used to explain fire before oxidation was understood. Why do things burn? Because they contain phylogistin. How do you know if something contains phylogistin, why if the substance burns, then it contains phylogistin! This is a circular form of reasoning.
In earlier times unusual behavior was explained by the person being possessed by demons, evil spirits or witches. These were invoked in order to understand behavior that was otherwise puzzling. "Mental illness" is used to explain bizarre behavior today in much the same way as witches or evil spirits were invoked earlier but in the shroud of scientific legitimacy. Homosexuality was regarded earlier as a psychopathology and now is regarded by the psychiatric establishment as a matter of personal choice. What changed was only our mind-set.
Bizarre behaviors are believed to be symptoms of underlying diseases and persons are relegated to the medical profession for treatment. Various frameworks have been used to explain deviant behavior. The same behavior from a religious perspective can be viewed as a sin, from a criminal justice perspective as a crime, and from a mental health perspective as a sickness, and from a sociological perspective as deviance. The "medical model" becomes a framework within which the behavior is interpreted. Explaining bizarre behavior as a result of mental illness is accepted more readily as having a scientific basis. Yet despite its introduction, it does not improve our understanding of the behavior any further than did the supernatural explanations such as possessed by evil spirits. It is all a matter of social definition. We lack scientific evidence that underlying mental diseases cause all these various forms of bizarre behaviors. This does not mean that none of the bizarre behavior can have a biological cause; some very obviously do such as brain tumors. Sociologists have described the increasing medicalization of various forms of deviance such as alcoholism or drug addiction, eating disorders, attention deficit disorder, obsessive compulsive disorder, and various other so called syndromes or diseases. Almost every unaccepted pattern of behavior is now labeled as a syndrome. While in one sense it decreases the blame toward the individual by calling it an illness, it sheds little light on the processes that generate the behaviors.
These explanations are circular. Why does someone commit suicide, because they are mentally ill. What is the proof they are mentally ill, because they attempt to take their life.
"Mental Illness" is a complete social construct that is devoid of objective reality. Scheff asserts it is not a disease but a social role and proceeds with identifying the causes of labeling the individual mentally ill and thus casting them into a new social role. II. The second focus of Scheff's theory is to explain why people get labeled as mentally ill.
Since mental illness does not exist, Scheff studies why people get labeled as mentally ill, in the same fashion he might have studied why people were labeled as witches in earlier times without necessarily assuming that witches exist.
Scheff asserts that the labeling of someone as mentally ill results from a particular form of deviance, the violation of residual rules in society. Residual rules are norms, which are so agreed upon that they are regarded as "natural" ways of behaving rather than accepted social conventions. Most people can see the side of the road we drive on or the criminalization of marijuana, are arbitrary conventions of society. Yet if we saw someone talking nose-to-nose, talking to themselves, manifesting inappropriate affect or logic, etc., that there was something wrong with them, they were crazy, not that they had violated a norm! Most people could not even conceive of residual rules as arbitrary rules. What Scheff suggests is each of the behaviors that are regarded as psychiatric symptoms, are nothing more than violations of accepted rules of social comportment.
There are rules that regulate affect, and if you violate these by crying on a happy occasion or laughing on a supposedly sad occasion or displaying affect toward objects that were not regarded as appropriate, then you would be labeled as mentally ill. Rather than seeing these as signs of an underlying illness, they are nothing but violations of various rules in society. There are rules that define what is real, and if you violate these understandings you have lost touch with reality and are psychotic. There are rules about how to think and people who violate these rules think in a crazy way. Hundreds of thousands of such rules exist which can result in your being defined as mentally ill. In fact if you examine each so called psychiatric symptom, underlying that symptom would be a violation of a residual rule (Goffman).
A second meaning of the term residual is of a leftover category. There are labels for violators of criminal laws, criminals, and violators of rules of acceptable use of alcohol are called alcoholics, violators of sexual mores are called perverts, and persons not conforming to work ideals are called bums. But there are many rules not categorized, and we have no specific terms to label these individuals. They are all lumped together in this residual category and referred to as mentally ill. What may be not explored are socially acceptable or understandable reasons for the violation of a residual rule, which may mitigate labeling.
Similar to other norms, residual rules are not applied uniformly to all persons. There are contingencies in labeling: not everyone is equally likely to be labeled when they violate residual rules. A poor person who thinks others are poisoning them would be likely to be diagnosed as paranoid and institutionalized, while a rich person, like Howard Hughes, would be regarded as eccentric even if he hired full time food tasters. The act the person engages in, when and where they engage in the act and whose interests are injured by the act, all play a role in the likelihood of becoming labeled as mentally ill. Hollingshead and Redlich found lower class persons were more likely to be forced into psychiatric treatment by formal authorities, while those of the upper class were more likely to be self referred.
The function of labeling: Why does labeling exist in society? Labeling protects threats to the status quo and the values of society. By labeling the person who departs from our common understandings, it reinforces and affirms the threatened social values and existing social arrangements. You don't have to justify money as a value when you call someone crazy who destroys it or exchanges it for things of lesser or no value. The person rather than the value or system is seen at fault.
A second function of labeling is to protect social reality. As suggested, symbolic interactionism relies upon the notion that reality does not exist out there but is socially constructed. These shared understandings of reality make society possible. And because our beliefs are grounded in this social reality which is believed to be based on social consensus, when people act differently it threatens the underlying foundation of social values and social consensus. Since many of our most important beliefs cannot be tested by physical reality, we believe in them more strongly, to the degree that others also confirm our confidence in them. To the extent you proclaim realities not supported by others, you are regarded as being out of touch with reality and hence psychotic!
Which model governs out understandings is important because interactions driven by the medical model, as a mind set, determines what players become involved in the process of social control and how the individuals will be responded to and attempts at modifying their behavior will be undertaken. III. Some Consequences of Labeling Persons as Mentally Ill:
A third aspect of Scheff's theory examines the effects of labeling people as mentally ill and introducing the medical establishment to regulate the behavior. Scheff suggests that much of the aberrant behavior observed in these individuals is the product of a system of typing and labeling individuals as mentally ill, and the institutional apparatus brought to bear upon them.
When people engage in residual rule breaking behavior, the audience can respond in one of two possible ways. One is to overlook, normalize or deny the deviance, as people frequently avoid facing problems. By avoiding labeling the individual, Scheff suggests that most likely outcome of the behavior is that it will be self-limiting. A second way people can respond is to label the person as mentally ill with the resultant stigma that it entails. It is this path that amplifies the aberrant behavior into a more enduring manifestation of deviance, career deviance, in society. This results in a serious of process being elicited.
A. When the individual is labeled as mentally ill they are placed in a new social status, a deviant status. A deviant status is a stigmatized status where the individual is rejected, devalued, isolated or relegated to a second-class or inferior status. Individuals can face their loss of freedom through institutionalization, invasive drug and medical interventions, serious discrimination from others that impairs their ability to obtain employment, housing, and social acceptance.
B. After the individual is effectively labeled, this alters others expectations of them, and unleashes a new and powerful social force. Once people are placed in a role, especially a deviant role, this becomes a powerful social force upon them. Rather than people simply playing social roles, roles begin to play the people occupying them and transforming them sometimes fundamentally.
C. Once persons are placed in a deviant status, others come to look down upon them, and their expectations about them begin to change. Others expectations are a powerful social force. After medicine men were observed diagnosing serious illness through bone divination sometimes the patient died shortly after such a diagnosis. Patients suffering from heart arrythmia who were told about their condition were more likely to suffer heart attacks than those who were not informed about their condition.
Many deviants such as criminals, addicts, prostitutes, perverts, etc. are also often excluded from the community, rejected within the community, and experience prejudicial reactions from others in the group. Some groups who are not even accused of having done anything wrong, such as minorities, the physically disfigured, or aids patients, are also treated as stigmatized persons in society.
D. Once the person is cast into a deviant role, they are rewarded for playing the role and punished for deviating from it. A patient sent to a mental hospital by the court for observation did not cooperate with the psychiatrist who was leading the group therapy he was required to participate in. The psychiatrist then placed in their chart comments suggesting their lack of insight required more hospitalization. When the patient was informed by other patients that the psychiatrist had the power to keep him institutionalized, he shaped-up and found some "problems" for the psychiatrist. He was treated much more favorably after that by the psychiatrist. Patients, like McMurphy in One Flew Over the Coo Coo’s Nest, suffer the ultimate punishment, lobotomy or electric shock, for failing to conform to the mental patient role. The individual gets type-casted and has to conform to others expectations or suffer dire consequences. Scott (1969) illustrated how individuals who lacked vision were rewarded for assuming dependent behaviors as they took the role of the blind.
E. The next stage is role freezing. Once you have been excluded from society in a prison or a mental hospital, it is difficult to re-enter the mainstream of society. It is difficult to get a job, apartment, or social acceptance and you are regarded forever as an ex-mental patient or ex-convict. There are status degradation ceremonies such as court trails which taint your identity and degrade you to a deviant, but none that return you to normalcy and social acceptance. Stigma is almost a non-removable stain on your character, and may even tarnish those with whom you are closely associated.
F. The next stage is the development of a deviant identity. Identity and self-concept refer to how you think of yourself. Others evaluations of us are internalized through the "looking glass" self. The self arises out of social interactions. We develop reflexive behavior and while acting and are able to observe and react to our own actions. Cooley asserts we think about ourselves as we imagine how others have thought of us. We come to think about our self, based on others' reactions toward us. If they regard us as insane, we too will begin to see our self in that same light.
G. The self-fulfilling prophecy then comes to influence our subsequent behavior. How we think about our self will influence our actions. This is the "self fulfilling prophesy." Rosenthal's ( ) study, the Pygmalian effect, demonstrated how teacher's expectations influenced student's academic achievement. Once you are labeled as a deviant, you come to start believing it, and tend to act upon that definition of yourself.
H. The fulfillment of the process culminates in a deviant career. Frequently the deviant tends to isolate them self from conventional society and sometimes embedded in deviant subcultures. Once the individual gets tracked into a formal system of deviance it is hard to escape and it becomes an embedded way of life sometimes with a lifetime of circulating in and out of hospitals or psychiatrists offices trapped in what is described as career deviance.
However, if your deviance is denied, Scheff argues, it is likely to be transitory since such behavior is often self-limiting. Many have had imaginary playmates and temper tantrums growing up, that over time disappear. If the behavior had resulted in the labeling of the individual, it likely would become stabilized into a deviant career. The process of being placed in an institution leads to de-socialization and a kind of dependence described as institutionalization. Thus the belief that early diagnosis and early treatment lead to an early cure only applies to cancer. In mental illness, diagnosis and treatment only lead to more aberrant behavior.
Evidence in support of Scheff's theory:
Glass's ( ) study of the military during the Korean war indicated when soldiers received psychiatric care, 80% had to be discharged as unfit for military service. The failure rate of traditional psychiatric treatment was 80%. Among those soldiers who had psychological traumas, but received no psychiatric treatment and their episodes ignored, only 20% had to be discharged. The lack of psychiatric treatment reduced the failure rate from 80% to only 20% who ultimately had to be discharged from the military.
Labeling and institutionalization create much of the bizarre behavior that persists among mental patients. Treat people as if they were crazy, incompetent, childlike, etc. and they become those types of persons. They become how they are beheld.
In Mendel's ( ) study, patients were randomly assigned to 7, 14, and 30-day wards on a mental hospital. They were then subsequently discharged from the ward after that time period. The results of his study showed the longer the person stayed in the hospital, the less likely their symptoms remitted, the poorer their adjustment to the community, and the earlier they were rehospitalized when compared with patients who stays were shorter in the hospital. Psychiatric treatment and hospitalization made their problems worse rather than better. This is referred to as "iatrogenic" illness, an illness, which is caused by the medical treatment itself.
Scheff suggests hospitals are factories for creating madness in the same way prisons are factories for creating criminals. There is an ironic contradiction in that we set up institutions like mental hospitals and prisons to alleviate problems, but they actually make them worse. Mental hospitals often make the problems of the individual worse. (Nancy and Barbara in state hospitals)
The Effectiveness of Psychiatric Treatment:
Esyenk's ( ) earlier evaluation of studies of the effectiveness of psychotherapy showed generally 1/3 of the patients get better, 1/3 stay the same, and 1/3 get worse during treatment. Is it encouraging news that 2/3 get better or stay the same? Yes, if all the patients would have gotten worse without therapy. Yet we did not know how patients would fare without psychotherapy until a study ( ) at UCLA that showed the recovery rates for those persons on the waiting list for treatment fared as well as those who received treatment. Thus there was no proven benefit of psychotherapy.
Other criticisms of Scehff’s theory include Gibbs (1972) and Davis (1972) that argue the concepts in labeling theory are ambiguous and do not have a single denotative meaning, to which Scheff replies that is true of the medical model as well. Gove (1970) asserts that the empirical evidence supports the medical rather than the sociological model. Effect of institutional life on the staff: It is clear that most institutions of social control have deleterious effects on the inmates in them. What about the effect on those who work in these institutions? The effects of prisons, mental hospitals and other institutions of social control on the staff and people who work in them have not been sufficiently explored. Newspaper exposes have shown that many psychiatric attendants brutalize patients. Periodically charges are brought against staff for brutalizing inmates or patients. Is this due to the type of people who come to work in these institutions? Studies of psychiatric aides ( ) showed that on many psychological tests, they were as sick, or sicker than the patients. What kinds of people would be drawn to work at an occupation that has low pay and prestige but enormous power over individuals?
A study conducted at a state hospital showed a normal range of individuals applied for and were hired for the position of psychiatric aide. A follow up of attrition showed after six months, that the most desirable individuals tended to leave the employ of the hospital. Training, however, improved almost all staff that remained. Six months after training and assignment to regular wards in the hospital, attendants showed a marked deterioration in their attitudes. Their attitudes changed in the direction of their coworkers on various wards. If the other employees on the wards were treatment oriented, they maintained their positive outlooks, showing the importance of the staff culture. However, since most wards in the hospital were custodially-oriented, a mark shift occurred over time towards greater custodialism and authoritarianism in the aides. Staff, like the inmates, became institutionalized.
Another study of professional staff and their abilities to create and sustain healthy relationships, showed over 92% of psychiatrists, 90% of psychologists, and 70% of social workers who worked in a state hospital had been divorced at least once. Even those mental health professionals who had stable relationships, they were fraught with problems. Few of the therapists also reported as having close friendships, most tended to be isolated from close interpersonal relationships. When these findings were reported to the professional staff at the mental hospital, many argued that these professions tend draw already troubled individuals.
A sociological perspective suggests it is the role, organization and character of work that causes this relationship. The staff that had intact close relationships were the ones unlikely to work directly with patients, they were supervisors or paper shufflers. To demonstrate it was the role more than the nature of the person which impaired their relationships the length of time in the role was examined. The longer they worked in their role, the more pronounced was its effect, and the higher percentage of staff who had impaired interpersonal relationships. Working in such institutions dehumanizes individuals, creates burnout, and reduces capacity for fulfilling social relationships. Dentists, for example, have high rates of suicide. Initially they develop insensitivity to the pain they are causing their patients and protect themselves by tuning out. Later they may become unresponsive to any emotions of others and like a suit of armor, what at first protects them, later imprisons and isolates them. This work may create cold and detached people and burns out and damages people. Most occupations have effects on people's lives. Caring human beings get eaten up by these brutal systems. Therefore steps must be taken to protect staff from these hazards so these institutions do not create further harm to those already marginalized by society.