Routledge International Handbook of Critical Mental Health

Bruce Cohen, Bruce M.Z. Cohen, Bruce Cohen, Bruce M.Z. Cohen

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138225473
• eBook ISBN: 9781315399560
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

The Routledge International Handbook of Critical Mental Health offers the most comprehensive collection of theoretical and applied writings to date with which students, scholars, researchers and practitioners within the social and health sciences can systematically problematise the practices, priorities and knowledge base of the Western system of mental health. With the continuing contested nature of psychiatric discourse and the work of psy-professionals, this book is a timely return to theorising the business of mental health as a social, economic, political and cultural project: one which necessarily involves the consideration of wider societal and structural dynamics including labelling and deviance, ideological and social control, professional power, consumption, capital, neoliberalism and self-governance.

Featuring original essays from some of the most established international scholars in the area, the Handbook discusses and provides updates on critical theories of mental health from labelling, social constructionism, antipsychiatry, Foucauldian and Marxist approaches to critical feminist, race and queer theory, critical realism, critical cultural theory and mad studies. Over six substantive sections, the collection additionally demonstrates the application of such theoretical ideas and scholarship to key topics including medicalisation and pharmaceuticalisation, the DSM, global psychiatry, critical histories of mental health, and talk therapy.

Bringing together the latest theoretical work and empirical case studies from the US, the UK, Australia, New Zealand, Europe and Canada, the Routledge International Handbook of Critical Mental Health demonstrates the continuing need to think critically about mental health and illness, and will be an essential resource for all who study or work in the field.

Part I
Theoretical perspectives

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1
Labelling theory

Stefan Sjöström

Labelling theory is one of the most influential theoretical approaches that has been systematically applied to understand mental illness as a social phenomenon. It can be seen as a social constructivist approach with a kinship to notions such as medicalisation, stigma and normalisation. Broadly speaking, labelling theory takes an interest in the social processes whereby certain people are defined as ‘deviant’ by society. This always involves certain power dynamics, and the labelling is often understood as a form of social control. Groups that in various respects disturb dominant views of social order might be labelled as deviant – for example, ‘criminals’, ‘adulterers’ and ‘homosexuals’. Since its introduction in the early 1960s, labelling theory has inspired empirical research into a wide variety of mental health issues investigating lay as well as professional settings. Labelling theory has fuelled intense debates regarding both the extent to which it can be verified empirically and what theoretical and epistemological implications it brings about. Furthermore, the specific application of such theory to mental illness has stimulated new theoretical discussions among those interested in labelling theory as part of a more general approach to deviance. This chapter discusses the labelling theory of mental illness as originally presented by Thomas Scheff in 1966, as well as the debates and developments that have followed his work. Within a mental illness context, the discussion of labelling theory has a natural starting point in Scheff’s book Being Mentally Ill: A Sociological Theory (1966). His work was part of a broader strand of research on labelling and deviance founded in symbolic interactionism. The early contributions were primarily made by scholars interested in crime such as Tannenbaum (1938) and Lemert (1951), but also with other deviant groups in focus such as the classic research on drug takers from Becker (1963).

Deviance and labelling: a general perspective

Perhaps the most influential contribution to the early development of a general labelling theory is Howard Becker’s book Outsiders: Studies in the Sociology of Deviance (1963). Becker is concerned with the social interactions leading to someone being recognised as a deviant, or an ‘outsider’. He notes that this happens when someone violates formal or informal rules. For example, a person who spends a lot of time playing poker may be degradingly called a ‘gambler’. Although the identification of deviant behaviour may appear trivial, Becker points out that there is vast variation in whether a rule violation leads to the individual being identified as a deviant. Rules are broken constantly and very often without any reaction from others. Nevertheless, Becker noted at the time of writing in the 1960s that the research on deviance had been far more occupied with the people who had broken the rules rather than those who made up and enforced those rules (and, arguably, outside a very limited field of research inspired by labelling theory and similar approaches, the same can be said about research into deviance today). Instead, Becker concluded that deviance should not be regarded as an inherent quality of rule infractions by deviants; the decisive factor determining when someone will be labelled as deviant is the reaction from others. Thus he argues against a strong common sense notion that deviance primarily stems from ‘within’ the people who break the rules. This position has political implications, since it serves to relativise deviant acts and puts emphasis on the power dynamics involved when certain behaviours, individuals or groups are labelled as deviant. Becker notes that, apart from legal powers, social structures and hierarchies (in terms of ethnicity, social class, gender and generation) form what is constructed as deviance in a given time and place. The negative reactions and potential sanctions to deviant behaviours are mediated through moral entrepreneurs, who in turn can be divided into rule creators and rule enforcers. Becker discusses the former in terms of moral crusaders who advocate that certain behaviours are unwanted and should be sanctioned by society. Modern examples of behaviours that have been questioned by moral crusaders include excessive computer gaming and public smoking. If they are successful, the behaviours moral crusaders object to may become viewed as deviant by larger groups in society. For example, clergy in certain Islamic contexts create rules about what clothing is appropriate for women to wear. Under certain conditions, such rules will be enforced widely in a society or subculture. The arbitrariness of such rules is obvious when we consider how the same items of clothes that are prescribed in some cultures may be banned in others. Becker also argues that the actual labelling of a behaviour as deviant can feed back to the rule-breaker in a way that reproduces and reinforces patterns of deviant behaviour. This can be understood in terms of deviant careers, where people may adopt a deviant identity, learn how to manage their deviant behaviour (improve it, hide it, rationalise it and so on) and become part of a subculture – all of which reinforces the negative reactions from those representing a ‘normal’ way of life. Becker argues that, especially with regards to features that define identity (e.g. Afro-American, gay and so on), these mechanisms can be so powerful that the labelling of someone as deviant can produce a self-fulfilling prophecy.

Thomas Scheff on the labelling of the mentally ill

Drawing from the work of Becker and others, Thomas Scheff (1966) then undertakes his comprehensive study of how mental illness can be understood in terms of labelling. His theory of mental illness is contrasted against a medical model which conceptualises the source of mental illness as residing within the individual; consequently, treatment measures aim at modifying internal patterns, whether psychological or neurological. What is unique in how people are labelled as mentally ill, Scheff argues, is the type of rule-breaking that instigates reaction from others. Broadly speaking, there exists a wide variety of more or less well-defined formal and informal rules in society, and people are generally capable of attaching certain types of deviant label to behaviour that breaks those rules. However, there also exists a residue of subtle, often unspoken rules that have no obvious connection to forms of deviance that already have a label. These are what Scheff calls residual rules, the rules at stake when someone is labelled as ‘mentally ill’. Scheff claims that most features that are viewed as psychiatric symptoms can be regarded as residual rule-breaking. For example, this would be the case when someone talks back to her internal voices, claims that she is the saviour of the world or insists that her life is so dull and meaningless that even her close family would be relieved if she was dead. Drawing from Goffman’s (1963a) work on behaviour in public places, Scheff puts emphasis on the tacit rules governing everyday human interaction. He thus suggests that what Goffman has described as rules of engagement (for instance, not to withdraw too much, having a purpose and so on) qualify as residual rules. In developing his theory, Scheff presents nine fundamental propositions, some quite well grounded in empirical research, some more conjectural:

1. Residual rule-breaking arises from fundamentally diverse sources. Scheff differentiates between four distinct types of sources: organic, psychological, external stress and volitional acts of defiance. He shows how this transgresses a limited medical model understanding of mental illness as biological pathology and instead highlights the social sources of stress and volition. For Scheff, military combat or sleep deprivation exemplifies external stress. Other known external stressors include those related to working life and school settings. As for volitional sources, Scheff refers to art movements such as the French impressionists and the Dadaists. A contemporary example of volitional rule-breaking can be seen in forms of body piercing that appear objectionable to the majority.

2. Relative to the rate of treated mental illness, the rate of unrecorded residual rule-breaking is extremely high. Scheff cites the then-contemporary literature from the 1960s that indicates how psychiatric symptoms are, in fact, very common in the general population. More recent research seems to affirm this. For example, a large-scale study from Switzerland found that a considerable proportion of the general public displayed ‘psychotic’ experiences within a four-week period, with 38 per cent reporting that ‘someone else can control your thoughts’ and 43 per cent ‘feeling that you are watched by others’ (Rössler et al. 2007). This leads to the next proposition.

3. Most residual rule-breaking is ‘denied’ and is of transitory significance. Here, Scheff suggests that the normal response to strange behaviours is to ignore or forget about them without reacting against the rule-breaker. This is what makes labelling theory so powerful – shifting the attention from symptoms themselves to the social responses to rule-breaking as the major determinant of when a person will be diagnosed with a mental illness. This insight can be further corroborated by studies such as Garfinkel’s (1967) famous breaching experiments, where he analysed people’s reactions when faced with violations of ‘background expectancies’ or unspoken rules of everyday interactions (such as treating friends and family overly politely as strangers, saying ‘hello’ at the end of a conversation, bargaining for standard-priced items in a store and so on). Garfinkel found that people typically went to great lengths to normalise and make sense of such strange behaviours, and only imposed moral rejection as a last resort.

4. Stereotyped imagery of mental disorder is learned in early childhood. Although Scheff admits that this proposition lacks support in empirical research, it does appear plausible and on a par with what we know about the current negative perceptions of mental illness among the public (Angermeyer and Dietrich 2006), as well as the long history of ideas on madness (Foucault 1965; Scull 2006). The taken-for-granted ideas about madness and mental illness that have been established in Western society are, then, reinforced through contemporary culture.

5. The stereotypes of insanity are continually reaffirmed, inadvertently, in ordinary social interaction. Scheff notices how terminology related to mental illness is incorporated in everyday language. Cultural perceptions of mental illness are reproduced through popular culture and the mass media as well as ordinary, everyday interactions. The point here is how stable ideas about mental illness become, and how difficult it is to change them due to the variety of ongoing reproduction mechanisms. It is against the backdrop of cultural perceptions about mental illness that people, under certain circumstances, may start to interpret a person’s residual rule-breaking as a token of mental illness – the labelling process has thus been initiated. Due to the high prevalence of residual rule-breaking in society in general, there will always be a pool of earlier infractions to look back at and reinterpret in light of the new label; the recent behaviour can be seen as only part of a progress towards insanity. This process is facilitated by the fact that the labelled person, as part of the same culture, draws from the same cultural perceptions as those around her.

The next three propositions deal with how the person labelled reacts on being labelled and how she thus becomes inclined to accept the deviant role:

6.Labelled deviants may be rewarded for playing the stereotyped deviant role.

7.Labelled deviants are punished when they attempt the return to conventional roles.

8.In the crisis occurring when a residual rule-breaker is publicly labelled, the deviant is highly suggestible and may accept the proffered role of the insane as the only alternative.

It may make sense to the labelled person to adopt the classification that others have made. In fact, accepting and adhering to the labelled role may be rewarded. It may open possibilities to solicit help with material matters such as housing and welfare payments. Medical treatments such as tranquillisers can be attractive, and there may also be social and emotional rewards in the social engagement of professionals, family and friends in support of a person who accepts the role of being mentally ill. Conversely, the same benefits may be withdrawn if the label is taken away. Moreover, alternative interpretations and labels of her behaviour may be even more stigmatising – for instance, no one wants to be seen as being evil or stupid. In this context, Scheff highlights the role of ‘insight’, where a person is encouraged and rewarded when she accepts the ascribed role as being mentally ill. In fact, rejecting the label may even be seen as evidence that the person really is ill. Today, insight remains a key notion in psychiatric decision-making with regards to the involuntary commitment of patients (Diesfeld 2003; Diesfeld and Sjöström 2006; McSherry 2015). Scheff notes that, when residual rule-breaking occurs, there is likely to be some kind of crisis, both for the rule-breaker and the people around her. This will make the rule-breaker inclined to accept new definitions of who and what she is. All in all, there are strong feedback mechanisms that lead people who first might have only received subtle signals for residual rule-breaking to enter a process of labelling attachment and reinforcement. The first eight propositions outlined above form the basis for Scheff’s final proposition:

9.Among residual rule-breakers, labelling is the single most important cause of careers of residual deviance. (In the second edition of his book, Scheff (1984) relinquished the phrase ‘single most important’ from this proposition). This last proposition constitutes a serious critique of the medical model and the measures psychiatry applies to treat people labelled as mentally ill. If the problem primarily rests in processes of social definition and exclusion, argues Scheff, surely the methods to resolve the problem should take this into account. This view became a critical component in the various antipsychiatry movements that flourished in the 1960s and 1970s (Cooper 1971; Crossley 1998; Nasser 1995). Within this broad movement objections were raised against the inhumane treatment at large institutions (Belknap 1956; Goffman 1961), but also against the legitimacy of...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• List of tables
• Notes on contributors
• Preface
• Acknowledgements
• List of abbreviations
• Introduction: the importance of critical approaches to mental health and illness
• Part I Theoretical perspectives
• Part II Critical histories of psychiatry
• Part III Medicalisation and pharmaceuticalisation
• Part IV The politics of diagnosis
• Part V Colonial and global psychiatry
• Part VI Critical approaches to therapy
• Index