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