Being Mentally Ill

A Sociological Study

Thomas J. Scheff

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351328227
• Edition: 3
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

In incorporating social process into a model of the dynamics of mental disorders, this text questions the individualistic model favoured in current psychiatric and psychoanalytic theory. While the conventional psychiatric viewpoint seeks the causes of mental illness, Scheff views "the symptoms of mental illness" as the violation of residual rules - social norms so taken for granted that they are not explicitly verbalized. The sociological theory developed by Scheff to account for such behaviour provides a framework for studies reported in subsequent chapters. Two key assumptions emerge: first, that most chronic mental illness is in part a social role; and second, that societal reaction may in part determine entry into that role. Throughout, the sociological model of mental illness is compared and contrasted with more conventional medical and psychological models in an attempt to delineate significant problems for further analysis and research. This third edition has been revised and expanded to encompass the controversy prompted by the first edition, and also to re-evaluate developments in the field. New to this edition are discussions of the use of psychoactive drugs in the treatment of mental illness, changing mental health laws, new social science and psychiatric studies, and the controversy surrounding the labelling theory of mental illness itself.

I
INTRODUCTION

1
Biological Psychiatry and Labeling Theory¹

Although the last five decades have seen a vast number of studies of functional mental disorder, there is as yet no substantial, verified body of knowledge in this area, comparable, say, to medical knowledge of infectious diseases. At this writing, there is no rigorous and explicit knowledge of the cause, cure, or even a coherent classification of the symptoms of functional mental disorders (such as schizophrenia, depression, or anxiety disorders). Such knowledge as there is, is clinical and intuitive. 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.

During these five decades, most research on mental illness has sought to establish three main contentions:

Etiology (causation)	1.The causes of mental illness are mainly biological.
Classification	2.Types of mental illness can be coherently classified (DMS-IV).
Treatment	3.Mental illness can be treated effectively and safely with psychoactive drugs.

My argument about these claims will be based on a highly selective review of the relevant literature. My emphasis, for the most part, is on those studies that raise questions about the validity of the biopsychiatric approach. My review is probably as unrealistically negative as the biopsychiatric literature is unrealistically positive. A balanced review is yet to be made (for a recent attempt, see Chapter 3 of Mechanic 1999).

Many people have the impression that all three of the biopsychiatric goals have been reached. Articles by journalists usually assume as much. Indeed, most of the articles published in psychiatric journals at least imply that these three goals are already established or that they will be established shortly. They are taken for granted. Certainly in psychiatric practice it is now a truism that most cases of mental illness should be treated with psychoactive drugs. Indeed, many psychiatrists argue that it is unethical not to. Their effectiveness and safety is assumed not only by the majority of psychiatrists, but also by health maintenance organizations, which in insuring medical care, have come to have an enormous say in the practice of psychiatry. Needless to say, advertising by drug companies continuously brings these alleged truths before the public.

But these assumptions still have not been proven. The true picture is much more complex. In a recent editorial in the American Journal of Psychiatry, a biological psychiatrist (Tucker 1998) complained about the three goals. He argues that the system of classification developed in psychiatry (DMS-IV) does not actually fit many patients, and that it has only succeeded in distracting attention from the patient as a whole. His main objection, however, is that the syndromes outlined in DMS-IV are free-standing descriptions of symptoms. Unlike diagnoses of diseases in the rest of medicine, psychiatric diagnoses still have no proven link to causes and cures. As Tucker says, making a point about both classification and causation: “All of this apparent precision [in DMS-IV] overlooks the fact that as yet, we have no identified etiological [causal] agents for psychiatric disorders” (p. 159). This particular sentence exactly explodes the biopsychiatric bubble (see also Valenstein 1998).

This article is especially noteworthy because it appears in the flagship journal of the American Psychiatric Association, the main psychiatric association in the United States, the home country of biological psychiatry. The most widely read of all psychiatric journals, until 1998 it relentlessly promoted the threefold objectives of biological psychiatry. This direction now seems to have slightly shifted, however, suggesting that the dominance of biological psychiatry may be coming to an end.

A second article challenging the position of biological psychiatry was published in the same journal soon after the Tucker article, reviewing studies that support interpersonal causation in the origins and outcome of mental illness (Lewis 1998). Lewis proposes ten central premises of the interpersonal school of psychiatry, and reviews studies that show the effectiveness of secure adult relationships in undoing the adult consequences of destructive childhood experiences, and the role of well-functioning marriages in decreasing depression. The appearance of the editorial and the special article in the AJP that challenge fundamental tenets of biological psychiatry may signal the beginning of the end of its dominance.

Even during the years of biological dominance, there has been a steady stream of studies that raise crucial questions about each of the three major strands. The status of claims of biological causation and systematic classification have always been ambiguous. Obviously there have been significant advances in knowledge about the interaction of biological and nonbiological factors in mental illness. A representative study of rates of occurrence of schizophrenia in Finnish twins can serve as an example (Tienari and Wynne 1994). Tienari and Wynne found that the rate of schizophrenia in the “adopted-out” twin born to a schizophrenic mother was manyfold greater than in the population at large, suggesting a genetic factor. But on the other hand, even though the rates were high, still most of the adopted twins with a schizophrenic mother were not diagnosed as schizophrenic, suggesting a nongenetic origin.

To confirm a genetic cause, even for only one part of those diagnosed as schizophrenic, the deficit gene would have to be isolated. Although studies of DNA report promising areas of exploration, this step has yet to occur. Like the claim earlier in the century that psychoanalysis was on the threshold of a breakthrough, the claim of genetic causation seems premature (Grob 1998).

The classifications of psychiatric disorders that have been organized into the succeeding DSM versions appear to be little more than attempts to confirm current psychiatric practices, rather than empirical studies. Empirical studies usually show broad discrepancies between diagnostic categories and patient symptoms. An example is the study of symptom clusters by Strauss (1979), a widely respected research psychiatrist. He compared the actual cluster of symptoms that each of 217 first-admission patients displayed with the diagnostic syndromes. He concluded that the clusters of “the vast majority [of the patients] fall between syndromes.” That is to say, the symptoms of the large majority of actual patients do not cohere the way the DSM organizes them, suggesting that, in this fundamental respect, the problems that psychiatrists treat do not seem to fit into the medical model of disease (also see Mirowsky 1990).

Researchers from social work have published two books suggesting that the DSM classifications are determined much more by the politics of psychiatry than by evidence (Kirk and Kutchins 1992; Kutchins and Kirk 1997). In the first book (1992) they show that evidence that would confirm the DSM classifications is vanishingly small.

The strongest strand of the biological revolution in psychiatry has always been treatment with psychoactive drugs. In the early years of their use, these drugs were seen as ways of controlling and dispelling the symptoms of mental illness, if not as absolute cures. Especially when compared to psychological and social measures, drugs were seen as being cheap, quick, safe, and effective. There is still no question about how quick, cheap, and easy to administer the drugs are. But in the last twenty years evidence that contradicts the effectiveness and safety of psychoactive drugs has been becoming available. There are also indications that these drugs may be administered to manage or control certain categories of patients, rather than to help them.

EFFECTIVENESS OF PSYCHOACTIVE DRUGS

There are a vast number of systematic studies that seem at first glance to testify to the effectiveness of psychoactive drugs. These are almost all what is called randomized clinical trials (RCTs), carried out using the standard design for scientific experiments. A group of patients with similar diagnoses are divided randomly into two subgroups. One subgroup, the treatment group, receives the drug, the other, the control group, gets an inert substance disguised as a medication, a “placebo.” The design requires that the administration of the substances be “blind,” that is, neither the patients nor the doctors know which are the drugs and which placebos. If the subgroups are set up at random, and if the participants are “blind,” then any change in the treatment group larger than the control group can be confidently ascribed to the effects of the drug.

The usually positive results of these studies are thought to demonstrate two points: (1) that psychoactive drugs are more effective than the placebos used in the control groups, and (2) that their effectiveness is due to the correction of biological deficits in the patients. However it is important to note that even if these results are accepted at face value, the average difference in effect between the drug and the placebo group in the typical study is not large and is often short-lived, as shown in studies over time. Typically, in repeat studies done from four to eight months after the initial one, the average advantage of the treatment group over the control group has decreased or even disappeared. Since we are dealing with averages among many patients, this is not to say that there aren’t strong positive and negative, and even no effects on individual patients. To summarize: even accepting the validity of the RCTs, most psychoactive drugs are only slightly and briefly more effective than placebos. The decreasing effectiveness over time is suggestive of a placebo effect.

In recent years many studies have challenged the standard interpretation of the RCT studies, that psychoactive drugs, in themselves, are more effective than inert substances, and that their effectiveness is due to the correction of biological deficiencies. It now appears that most RCTs are not truly blind, because most of the participants can make accurate guesses as to whether the patient is receiving a psychoactive drug. Shapiro and Shapiro (1997, Table 9.1) reviewed 27 studies that asked doctors, patients, and “raters” (outside observers) to guess who was receiving the drug.

On average, 93% of the doctors, 73% of the patients, and 67% of the raters could accurately guess the active agent. Doctors, patients, and raters can use physical effects, taste, color, texture, and dissolvability to guess. Especially for the patient, the physical effects on the body often reveal the active drugs, since many of them are powerful stimulants, sedatives, or emotion blockers. The drug companies who conduct most of the RCTs seldom try to make a close match between the drug and the placebo, because they think it is not sufficiently important to warrant investing in the complex task of precise matching. In a scholarly review of this issue, Healy (1997) is also critical of the use of RCTs in evaluating the effects of antidepressants.

In my opinion, even a careful attempt at precise matching would face an insoluble dilemma. If the placebo were precisely enough matched to the medication, then its own effects on the patient would make the results of the experiment ambiguous. I think that experimental designs that necessitate blind administration of medicine and placebo are inappropriate for human beings. Case studies are more appropriate. Although they also involve reliability problems, they are nearer to the surface. The RCTs hide validity and reliability problems behind the mask of hard science. For a proposal to apply the case study method to the problem of evaluating drug effects, see Jacobs and Cohen (1999).

If the great majority of the participants are not truly blind, then the validity of the entire method of research is thrown into question. The purpose of the RCT design is to rule out all explanations other than the biological effect on the patient. If most of the patients and doctors in the studies know which medications are active, the possibility arises that some or even most of the effects are psychological and/or social.

PLACEBO REACTIONS

This possibility is known as “the placebo effect.” It has been documented that all substances prescribed by a physician, even if they are inert, can have powerful effects on the patient (Fisher and Greenberg 1997; Harrington 1997; Shapiro and Shapiro 1997). The processes that give rise to this effect are not well understood. It is believed, however, that the social psychology of hope, both in the doctor and in the patient, plays an important role.

Even in physical illness, the loss of hope can lead to deterioration of health independently of the disease process. For example, one study of 2,400 middle-aged men (Everson, Goldberg, and Kaplan 1996) found that hopelessness was the best predictor of death from heart disease and cancer. Six years after the initial interview, the 11% of the men with the highest level of hopelessness had died at three times the rate of the men who were hopeful. Hopelessness was the best predictor of death or illness even in those men who had no prior history of heart disease or cancer.

In mental illness, the effect of hope is probably still greater. Anything that can increase the patient’s hopefulness can be potent medicine. In understanding the effects of psychoactive drugs on doctors and patients, it is important to remember that before “the tranquilizer revolution,” many psychiatrists believed that there was nothing they could do to help their patients, especially their psychotic patients. Perhaps the chief effect of these drugs, particularly the anti-psychotic ones, has been on the psychiatrists, restoring their confidence in their own competence, and therefore their hope for the patients. The doctor’s hope, quickly sensed by their patients, could increase the patient’s own hope, and improve the relationship between doctor and patient, and therefore the whole social psychology of treatment of mental illness.

Of course many, many patients are themselves convinced that they have been helped by psychoactive drugs; they feel that the drugs they were given were instrumental in controlling their psychosis, depression, or anxiety. What is the harm to them if the help they got, in most cases, was entirely due to the placebo effect? This issue brings up the question of side effects of psychoactive drugs.

ARE PSYCHOACTIVE DRUGS SAFE?

Just as placebo effects accompany all substances prescribed by physicians, so also do side effects. It has been known for many years that some of the widely used anti-psychotic drugs (neuroleptics), such as Thorazine, cause neurological damage, even in small doses, if they are administered regularly (Cohen 1997). It is possible that all psychoactive drugs, including the mildest tranquilizers, have potent side effects. The side effects, unlike drug effectiveness, have not received enough direct research attention. Since the actions of most psychoactive drugs are complex and not understood, patients receiving them are being experimented on.

There are now many studies that demonstrate adverse effects of psychoactive drugs in a sizable minority of patients. Tardive dyskinesia is caused by Thorazine and other similar neuroleptics. If administered for as little as three months, even in low dosages, these medications will sooner or later cause severe neurological damage, tardive dyskinesia. In this syndrome, the patient loses control over his body, leading to involuntary spasms and tics that impair motor functions. Surprisingly, although this side effect is widely known, and many new neuroleptics have been introduced that are supposed to be less likely to cause it, Thorazine and the other offending drugs are still used widely (Cohen 1997).

Antidepressants have also been shown to have adverse side effects. One study (summarized by Ayd 1998) showed that these drugs led to profound apathy and indifference in 11% of the patients who receive the drugs. A second study (Settle 1998) reported that 20% of 207 consecutive admissions to a psychiatric hospital had psychoses caused by withdrawal from antidepressants. Surely in physical medicine any treatment that had such severe and frequent side effects would be peremptorily suspended from use. It is no longer clear that the benefits of psychoactive drugs outweigh the costs, even though a majority of psychiatrists, and all drug companies and HMOs, have persuaded themselves that this is the case.

In my own observations of persons who take psychoactive drugs, the reactions have been variable. In mental hospitals, by the middle of the eighties, virtually all of the patients were being given psychoactive drugs. Most of the patients were receiving at least two different drugs, some as many as five. Most of the patients I interviewed complained about adverse effects, hinting that they discarded the drugs. Some showed me how they were able to evade the drugs even if they were given them by nurses, by “mouthing” the drugs so that they could later dispose of them.

Some of my outpatient subjects were ambivalent about their drugs. Two of them had a quite similar reaction to lithium carbonate, a mineral still widely used to control mood swings in bipolar (manic-depressive) illness. Both reported that the mineral brought considerable relief from their mood swings, but also interfered with their mental and creative capacities. Both elected to discontinue.

On the other hand, a few of the hospital patients, and a majority of the people I knew as outpatients, told me that they were undoubtedly helped by their drugs, often spectacularly. In questioning them closely about drug effects, I usually found that these subjects were convinced to the point that they were impatient with my detailed questions. Some reminded me of persons who had had a religious conversion. They sang the praises of their drugs, and were not cooperative in responding to questions.

The psychiatrist Aaron Lazare (1989) found that many patients in the outpatient clinic he directed requested tranquilizers, even in cases when the psychiatrist thought other treatments were indicated. In response, Lazare developed a pro...