Being Mentally Ill: A Sociological Theory
Scheff, Thomas J. 1999. Being Mentally Ill: A Sociological Theory. New York: Aldine de Gruyter.
Rating:
8
Summary:
The book begins by arguing that the popular theory of mental illness – that it is biologically based – is not grounded in empirical data, “To date, no clearly demonstrable linkage between neurotransmission or genetics has been found for any major mental illness” (p. xii). The author takes this argument to the next step and argues that psychiatry is less a science than an art and that the entire psychopharmaceutical industry has a vested interest in continuing to claim that psychotropic drugs are effective despite substantial evidence indicating they are seldom more effective than placebos (see pp. 6 &12). As the author puts it, “ 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” (p. 3). Additionally, the author argues that psychiatry is one of the only professions (religion would be another one) where the need for the service is actually created by the existence of the service – people only become “mentally ill” when there is a body of professionals that exists to “treat” them (see p. 51). One example of this socially constructed need can be seen in a study discussed in the text, “Glass goes on to say that removal of the soldier from his unit for treatment of any kind usually resulted in long-term neurosis. In contrast, if the soldier were given only superficial psychiatric attention and kept with his unit, chronic impairment was usually avoided. The implication is that removal from the military unit and psychiatric treatment symbolizes to the soldier, behaviorally rather than with verbal labels, the “fact” that he is a mental case” (p. 110).
This ultimately leads the author to argue that most mental illness is actually social-psychological in nature and involves labeling theory. The basic argument of the book is that people have pre-conceived notions of what it means to be mentally ill and that they enact those notions either for ulterior motives (e.g., to get away from dealing with reality) or because they are ultimately categorized and labeled as mentally ill and thus they adopt the role of those who act that way (p. 86). The author also argues that mental illness, or what is labeled as mental illness, really should not be disconnected from its social context, even though that is regularly done in therapeutic settings, “One reason, then, that the behavior of alleged mental patients is thought to be meaningless is that the extremely brief and peremptory psychiatric and judicial interviews shear away most of the information about the context in which the “symptomatic” behavior occurred… The concept of disease, as it is commonly understood, refers to a process that occurs within the body of an individual. Psychiatric symptoms, therefore, are conceived to be a part of a system of behavior that is located entirely within the patient and that is independent of the social context within which the “symptoms” occur. It is almost a truism, however, among social psychologists and students of language that the meaning of behavior is not primarily a property of the behavior itself, but of the relation between the behavior and the context in which it occurs” (p. 180). In short, rather than viewing mental illness as a genetic or biological problem, the author is arguing that mental illness is socially constructed and conveyed through role adoption in specific social contexts.
Review:
I generally liked this book, though it does have one very significant problem that I will discuss below. I’m hesitant to accept the author’s purely social-psychological theory of mental illness, but I do believe that the real answer lies somewhere between the purely biological/genetic approach of most psychiatrists and the author’s theory.
The author makes another point about healthcare in general that I thought was worth noting. Anyone familiar with Type I and Type II errors in statistics will find this point intriguing, “Which error do physicians and the general public consider it most important to avoid: rejecting the hypothesis of illness when it is true, or accepting it when it is false? It seems fairly clear that the rule in medicine may be stated as: “When in doubt, continue to suspect illness.” That is, for a physician to dismiss a patient when he is actually ill is a Type 1 error, and to retain a patient when he is not ill is a Type 2 error. Most physicians learn early in their training that it is far more culpable to dismiss a sick patient than to retain a well one” (p. 104). And, as it turns out, in the very few studies that have been done locating at how often medical doctors commit Type I or II errors, it appears doctors are more likely to make Type II errors by a significant ration (in one study, 50:1 in favor of the Type II error) – that is, they diagnose someone as ill when they are not more often than they diagnose someone who is ill as not being ill (p. 105). The author makes this point in his discussion of labeling theory – the argument being that once a label is applied, the behavior of the patient begins to change. Thus, if doctors are more likely to label people ill even when they are not, they are actually contributing to the prevalence of disease, or, at the very least, disease symptomatology.
Another good point made by the author is that crime reporting concerning the mentally ill has the same negative effect as it does for race. Whenever a former mental patient commits a violent crime, the fact that the individual was a former mental patient is noted, just like when a black or Latino individual commits a crime. It is never specified in the news report when a mentally sane person commits a crime, nor when a white person commits a crime. As a result, the general sense in the popular consciousness is that former mental patients are more dangerous than people who have never been mental patients, which is not true (p. 79). The author ties this into the role expectations held by the general public concerning mental illness; those role expectations play a significant role both in determining the behavior of mentally ill people but also their treatment.
The major problem I had with the book is that, despite very clear and well-argued opening chapters, the second half of the book turned toward conversation analysis of psychiatric session transcripts without a clear explanation of what was to be achieved. It was mildly interesting to read the transcripts, but it was unclear both why the author turned to conversation analysis and what he hoped to gain from it. This change in analysis leads me to recommend the first half of the book but not the second.
Overall, even if the author overstates his theoretical position, I think what he has to say about the social-psychological origins of mental disease is important. It’s unfortunate there are so few voices making similar arguments in academic circles today – the use of psychotropic drugs seems to be out of control and it does not appear that anyone or any group has the wherewithal to rein them in. Additionally, this book is a relatively clear formulation of a social-psychological theory of mental illness, which is certainly worth reading for social researchers and mental health clinicians.