Review - Being Mentally Ill: A Sociological Theory
Third Edition
by Thomas J. Scheff
Aldine de Gruyter, 1999
Review by Duncan Double
Sep 2nd 2003 (Volume 7, Issue 36)

A re-issue of this classic book is welcome, now that sufficient time has elapsed to gain a historical perspective on so-called "anti-psychiatry". The first edition in 1966 propounded the labeling theory of mental illness and formed part of the identified corpus of anti-psychiatric writings. Although the author, Thomas Scheff, now recognizes the one-dimensional, rather than consilient nature, of a single disciplinary sociological perspective, a dichotomy was created between the biomedical model of mental illness and theories, like labeling theory, which maintain that mental illness is primarily of social origin. Scheff argues that the statement of a countertheory to the dominant biopsychiatric model, even if not totally valid, is worthwhile in itself.

New chapters have been added to previous editions with little change to the earlier text. The new material allows a fuller exploration of the claims of biological psychiatry and its rise over recent years. The original theory is also modified and extended by placing an emphasis on the emotional/relational world, using the social interaction between patient and therapist as an illustration. After the first edition, Scheff's research interests moved on to emotions and approaches to integrating theory and method. The initial theory tended to ignore emotional aspects and was predominantly cognitive and behavioral.

Of course, social deviance cannot be the total definition of mental illness, as the first edition of the book tended to imply. Other forms of deviance, such as criminality, exist in society. Social misfitting itself cannot be used as evidence, let alone sufficient evidence for diagnosing mental illness. It is important, though, to appreciate that the essential point of Scheff's theory is that the person recognized as mentally ill is the deviant for which society does not provide an explicit label. Of all the categories of norm violations, such as crime, perversion, drunkenness and bad manners, labeling someone as mentally ill is identified with residual rule-breaking. Here Scheff differs from Thomas Szasz, who contests the social nature of health and proposes the term "problems in living" as an alternative term for psychiatric symptoms. Sheff suggests that if Szasz had used the phrase "residual problems in living" he would have come closer to his solution to the issue of mental illness.

Even if a thoroughgoing sociological explanation of mental illness, in a Durkheimian sense, is unsuccessful, the social nature of psychiatric practice cannot be denied. Labeling theory does need to be taken seriously, as mental health practice is inevitably a form of social control. To be identified as mentally ill implies social maladjustment. Biological psychiatrists may play down any close tie between mental illness and social deviance because they wish to emphasize individual somatic abnormality. However, psychiatric intervention occurs in social context. The environment and milieu cannot be disregarded. Maybe if biological psychiatrists were clearer that Scheff's labeling theory applies to residual deviance, rather than rule‑breaking in general, they would be more prepared to consider it.

The theory proposes that stereotyped imagery of mental disorder is learnt in early childhood and is continually reaffirmed, inadvertently, in ordinary social interaction and in the mass media. Labeled deviants may be rewarded by doctors and others for conforming to the idea of how a patient ought to behave when ill and systematically blocked to return to the nondeviant role once the label has been applied. Labeling is seen as an important cause of ongoing residual deviance. Consistent with the more integrative approach of the revised edition, the last proposition has been changed from labeling being the single most important cause of careers of residual deviance to being merely one of the most important causes.

Scheff's theory is compatible with wider aspects of anti-psychiatry, such as the study of families of schizophrenics by Laing and Esterson in Sanity, Madness and the Family. This research describes the disturbed and disturbing patterns of communication that lead to the labeled family member being elected to the role of "schizophrenic". For R D Laing as much as Scheff, the label is a social event and the social event a political act.

As Scheff himself acknowledges, the main challenge to labeling theory has been empirical. In particular, work by Walter Gove has suggested that the evidence for labeling theory is so overwhelmingly negative that it should be abandoned. This is because of reasons such as the said lack of evidence for the idea of a self-fulfilling prophecy or a career of deviancy, and relative neglect of "primary deviance", the process of becoming deviant in the first place. The initial abnormality appears to be better described as psychological malfunction, rather than social deviation. At the time that Gove first stated his criticisms, Scheff engaged with them combatively, but he now contents himself with pointing to the supporting evidence of Bruce Link and colleagues and admitting that the evidence for his theory is still sparse and mixed.

Labeling and stigma are not inconsequential in the lives of psychiatric patients. Labels do have debilitating effects, even if there may be controversy about their role in the creation of deviant behavior. Following the criticisms of labeling theory, psychiatrists could be said to have become more aware of the negative implications of psychiatric diagnosis, particularly of schizophrenia. In fact, the need to define psychiatric conditions more clearly, as in operational definitions of mental disorders in DSM-III (the third edition of the Diagnostic and Statistical Manual of the American Psychiatric Association), could be said to have arisen in response to the criticisms of labeling theory. Most famously, the study by Rosenhan, when normal people were admitted to psychiatric hospital by pretending they were hearing a voice, created the impression that psychiatrists were applying vacuous diagnostic labels to people.

Assessment of the legacy of "anti-psychiatry" may be helped by re-issue of this book. An interesting connection is with the development of community care and human rights in mental health legislation. In a brief appendix, Scheff notes that the first edition of his book was regarded as the "Bible" of the group that wrote a bill that became the new mental health law for California, and later for the rest of the United States. The new law made it more difficult for people to be kept in hospital indefinitely, which in the long run could be said to have contributed to the subsequent closure of mental hospitals.

The historical status of the book is not the only reason for reading the new edition. As with many books that become well referenced, they are not always thoroughly read. The book deserves closer attention. For example, I do not think it has always been sufficiently emphasized that Scheff's theory of mental illness applies to residual rule‑breaking rather than deviance in general. There is still enough value in the labeling theory of mental illness for it to be restated and not dismissed. The new edition provides the opportunity for re-appraisal of labeling theory specifically and the legacy of anti-psychiatry in general.

© 2003 Duncan Double

Duncan Double, Consultant Psychiatrist and Honorary Senior Lecturer, Norfolk Mental Health Care Trust and University of East Anglia, UK; Website Editor, Critical Psychiatry Network.