Mental illness, as the eminent historian of psychiatry Michael MacDonald once aptly remarked, “is the most solitary of afflictions to the people who experience it; but it is the most social of maladies to those who observe its effects” (MacDonald 1981: 1). It is precisely the many social and cultural dimensions of mental illness, of course, that have made the subject of such compelling interest to sociologists. They have responded in a huge variety of ways to the enormously wide social ramifications of mental illness, and the inextricable ways in which the cultural and the social are implicated in what some might view as a purely intrapsychic phenomenon.
If psychiatry has typically, though far from always, focused on the individual who suffers from various forms of mental disorder, for the sociologist it is – naturally – the social aspects and implications of mental disturbance for the individual, for his or her immediate interactional circle, for the surrounding community, and for society as a whole, that have been the primary intellectual puzzles that have drawn attention.
How, for example, are we to define and draw boundaries around mental illness, and to distinguish it from eccentricity or mere idiosyncrasy, to draw the line between madness and malingering, mental disturbance and religious inspiration? Who has social warrant to make such decisions? Why? Do such things vary temporally and cross-culturally? How have societies responded to the presence of those who do not seem to share our commonsense notions of reality? Who embrace views of reality that strike others as delusional? Who see objects and hear voices invisible and inaudible to the rest of us? Who commit heinous offenses against law and morality with seeming indifference? Or whose mental life seems so denuded and lacking in substance as to cast doubt on their status as autonomous human actors?
Mental illness has profoundly disruptive effects on individual lives and on the social order we all take for granted. Erving Goffman, whose mid-twentieth century writings still constitute some of the most provocative and profound sociological meditations on the subject is perhaps best-known for his searing critique of mental hospitals as total institutions, engines of degradation and destruction that falsely put on a medical gloss (Goffman 1961). But he also spoke eloquently of “the social significance of the confusion [the mental patient] creates,” arguing that it “may be as profound and basic as social existence can get.”
He insisted, rightly in my view, that “Mental symptoms are not, by and large, incidentally a social infraction. By and large, they are specifically and pointedly offensive … It follows that if the patient persists in his [sic] symptomatic behavior, then must create organizational havoc and havoc in the minds of members [of society].” Characteristically, Goffman then proceeded to critique the response of our contemporary credentialed experts in the treatment of mental illness” “It is this havoc that psychiatrists have dismally failed to examine.” But he was equally scathing about many of his contemporaries in the sociological profession, who then sought to dismiss mental illness as a purely socially constructed category, a mere matter of labels. For sociologists who adopted this romantic view were equally guilty of playing down or ignoring the profoundly disruptive effects of madness on the individual and on society. (See Goffman 1971: 356-357.)
Accepting, then, that there is such a thing as mental illness (all the while acknowledging that some sociologists and even some renegade psychiatrists have questioned its reality, and still others have debated its designation as a specifically medical problem), a whole series of further questions then arise: How much of it is there, and how do we know, if indeed we do? What is its social location? Does that differ by class, by age, by gender, by race, by ethnicity, and so forth? Do these social variables have implications for the way mental illness is reacted to and socially managed? What are the costs of such episodes of mental disturbance to individuals, families, and society as a whole, and how are those costs distributed?
How have societies characteristically responded to mental illness, and what institutions have they constructed to contain and perhaps cure it? What changes in these responses have occurred over time, and what accounts for these changes? How has mental illness been conceptualized by professionals, but also by the laity? And how have these differing cultural meanings been captured, refracted, and distorted in popular culture? One could go on, and the body of this encyclopedia deals with an even broader array of sociologically relevant topics, but the vital importance of a sociological perspective on mental illness should by now be apparent.
It should come as no surprise to learn, then, that from the discipline’s first days, many sociologists have had something to say about the subject. Sociology as a discipline began to coalesce in the late nineteenth and early twentieth centuries in France, in Britain, in Germany, and the United States, at first often outside university settings, as in the British social survey tradition pioneered by Charles Booth (1889, 1891, 1892-1897) and Benjamin Seebohm Rowntree (1901), but soon enough within the walls of academic institutions. The earliest academic sociologists often secured niches in other disciplines – Durkheim’s first appointment at Bordeaux was in Social Science and Pedagogy and his later chair at the Sorbonne was as Professor of Education; and Weber’s at Freiburg was in Economics, as was his next appointment at Heidelberg, but soon enough the discipline managed to institutionalize itself as a separate and legitimate academic endeavor.
Durkheim played a critical role in this process in France, and aggressively sought to claim for sociology a distinctive realm of social facts, external and constraining on the individual. Much of his work thus had an overtly polemical cast, and even the subject matter he chose was often influenced by its value in establishing the intellectual legitimacy of sociology and its status as a distinct and autonomous science, and in demonstrating the unique power of “the social” in the explanation of sociological phenomena. “Every time,” he boldly and wrongly proclaimed, “a social phenomenon is directly explained by a psychological phenomenon, we may rest assured that the explanation is false” (Durkheim 1895: 129).
Two years later, he deliberately chose an apparently quintessentially individual act, suicide, and attempted to account for it in social terms. More precisely, he claimed to detect in the statistics on suicide a whole series of distinct regularities, and it was these regularities in suicide rates for which he proffered a sociological explanation (Durkheim 1897). Necessarily, he was thereby led to confront the question of insanity and its possible relationship to suicide – mental illness in both its most florid manifestations and in borderline examples of mental disturbance such as alcoholism and what was then called neurasthenia or weakness of the nerves.
To his own satisfaction, at least, Durkheim claimed to have shown that while all of these conditions might predispose an individual towards suicide, it was social factors rather than individual psychopathology that explained the rate at which people killed themselves. To the extent that socio-psychological states led vulnerable people to commit suicide, those states were themselves the product of sociological factors – in modern societies, most commonly the condition he labeled “anomie,” or the failure of the social order to regulate adequately the beliefs and behaviors of its members. (For critiques of Durkheim’s arguments, see Douglas 1967; Lukes 1973.)
If Durkheim and the Durkheimian school dealt with mental illness only tangentially, another major school of sociological thought that was emerging in the early twentieth century, the Chicago School led by Park and Burgess frequently tackled the subject more directly. In important ways, the sociologists trained at the University of Chicago were heirs to the social survey tradition that had emerged in late nineteenth century Britain. Park, Burgess and their students treated the city as their laboratory, and set forth to document its structures and its pathologies (Park, Burgess and McKenzie 1925). Like their British predecessors, the Chicago sociologists employed both statistical techniques and ethnographic observation, both mapping the statistical distribution of social problems and providing detailed ethnographic studies of their place in specific neighborhoods in the city.
Psychoses were only one of a number of what they termed social pathologies that fell under their gaze – alongside homelessness, alcoholism, suicide, homicide, prostitution, juvenile delinquency, and crime. Characteristically, the psychological disorganization that characterizes mental illness (and other forms of deviance) was linked to the social disorganization of particular communities – the prevalence of anonymous and transitory social relationships and the weakness of social ties, all associated with the breakdown of social controls. (For discussions of the Chicago School, see Bulmer 1984; Faris 1967.)
The culmination of this perspective on the sociological study of mental illness came with the publication in 1939 of Faris and Dunham’s monograph on Mental Disorders in Urban Areas, a volume which, its title notwithstanding, focused primarily on Chicago See Faris and Dunham 1939; and for an attempt to generalize their findings to other cities, Schroeder 1942). But in a broader sense, the fascination with deviance that the Chicago School exhibited, and the preoccupation of many of the sociologists it trained with ethnographic approaches to the study of social life can be traced in many of the works of post-war American sociology, not least many of the classic studies that emerged in the 1950s and 1960s devoted to the sociology of mental illness.
The Second World War and its aftermath marked a turning point for American social science, as for American universities more broadly. The mobilization of society for total war broke down the barriers – legal and ideological- to the expansion of central state powers, as well as finally vanquishing the Great Depression. The upshot was a vast increase in the size and reach of the American federal government, a development that proved permanent and that has only accelerated in the years since. In war’s shadow, there was little disposition to rein in the expanded scope of federal authority, and what resistance there was melted away with the outbreak of the Cold War in 1947.
Science, including social science, had played an enormous part in the war effort, and as the conflict drew to a close, efforts were made to rethink the role of science and society in the soon-to-be post-war world. The most notable instance of this new thinking was Vannevar Baush’s extended memorandum to President Roosevelt, subsequently published as Science: The Endless Frontier (Bush 1945). Written by the wartime director of the Office of Scientific Research and Development, it presented a wide-ranging overview of the conditions of scientific research, its potential contributions to public welfare, the reconfigerations that would be necessary after the war, and the potential role of Washington, both in securing the training of scientific talent, and in the prosecution of scientific research.
Though its primary remit was the natural sciences and medicine, it ranged broadly over its chosen terrain, and in the Truman administration it would serve as the inspiration for the formation of the National Science Foundation, and the National Institutes of Health, both of which would transform the environment for research and the nature of the modern university. The era of Big Science and the modern research university may be said to be its progeny. Where before the war, federal involvement in scientific and medical research, let alone the social sciences, had been vanishingly small, from the late 1940s onwards, and particularly once the Cold War broke out, it started down the pathway of exponential growth that has continued ever since. With burgeoning federal investment, the process of knowledge creation and major characteristics of the academic world were irrevocably altered.
Military conflict had an even more direct impact on the psychiatric sector. Modern industrialized and mechanized warfare has repeatedly had drastic effects on the mental health of military personnel, and the Second World War, like the first, saw a massive number of psychiatric casualties spawned by the horrors of combat. Many of these were permanently harmed, so that the military authorities faced the immediate emergency of coping with soldiers breaking down – the effects on fighting efficiency and morale – and the post-war problems posed by disabled veterans with grave and continuing psychiatric problems. The exigencies of wartime prompted a massive expansion in the number of medics deployed to deal with psychiatric emergencies, and a continuing expanded demand for psychiatrists after the war ended. The knowledge that, under enormous stress, even the apparently psychiatrically healthy broke down in large numbers, and the heroic status of these psychiatric casualties, also helped change popular attitudes to mental illness, and encouraged the psychiatric profession to believe that many cases of mental illness could be treated outside the walls of the mental hospitals to which the mentally ill had been traditionally sent (Scull 2010).
The consequences of this situation were many. Direct provision of mental health services remained a state rather than a federal responsibility, with the exception of a considerable increase in the number of veterans’ hospitals devoted to providing psychiatric services. But both the Veterans’ Administration and the newly established National Institute of Mental Health were soon pouring funds into the training of mental health professionals, and NIMH also embarked on a program of basic research in the mental health sector. Within psychiatry itself, a rapid shift occurred in the locus of psychiatric practice, as more and more professionals opted for the out-patient sector and the traditional mental hospitals were left with the dregs of the profession. The number of psychiatrists rose rapidly, and for at least a quarter century, the most ambitious amongst them for the most part embraced some version of Freudian psychoanalysis.
NIMH adopted an extremely broad definition of what constituted research relevant to its mission of understanding mental illness and improving its treatment. Indeed, the bulk of its research funding was directed to the social sciences, not to psychiatry, in part because psychoanalysts spurned the sort of research the agency was willing to fund, and in part because they were such unadept grantsmen. Though the great bulk of the social science funding went in turn to the discipline of psychology, a not inconsiderable fraction of the federal moneys were captured by sociologists, and for the three decades after the Second World War, much of the flourishing state of the sociology of mental illness can be attributed to this flow of federal research dollars (Scull 2011a; 2011b).
Some of this work was conducted intramurally, at the Laboratory of Socio-Environmental Studies headed by the sociologist John Clausen (1956), and at the Biometry branch, where the collection of systematic statistical data and the development of epidemiological research were encouraged. But much also took the form of NIMH training grants, and extramural research grants. Substantively, much of the work in the 1950s built upon the intellectual foundations provided by the Chicago School, in its dual emphasis on quantitative and ethnographic techniques. Large-scale studies of social class and mental illness, of mental illness and the family, and of popular conceptions of mental illness were undertaken, and in some instances stretched over several decades. The centrality of the mental hospital in the mental health sector both pre- and postwar, and the relevance of sociological perspectives for the understanding of these complex organizations meant that these too became a focus of much funded research.
In the early 1950s, much of this research was collaborative in nature, linking together psychiatrists or other mental health professionals and sociologists in a common endeavor. Notable examples include Stanton and Schwartz’s (1954) ethnography of the Chesnut Lodge private mental hospital, and the work by Hollingshead and Redlich (1958) and their team of researchers on social class and on family dynamics and mental illness (Myers and Roberts 1959; see also Leighton, Clausen and Wilson 1957; Rennie and Srole 1956; Greenblatt, Levinson and Williams (1957); Yarrow, Schwartz, Murphy and Deasy (1955)). Soon, however, sociological work began to embrace a far more critical stance towards psychiatry and psychiatric institutions, a shift in intellectual perspective that emerged particularly strongly in studies of mental hospitals and of institutional psychiatry.
The altered intellectual stance was evident as early as 1956, with the appearance of Ivan Belknap’s study of a Texas mental hospital, with its conclusion that “mental hospitals are probably themselves obstacles in the development of an effective plan of treatment for the mentally ill” so that “in the long run the abandonment of the state hospitals might be once of the greatest humanitarian reforms and the greatest financial economy ever achieved” (Belknap 1956: xi, 212). It is equally evident in such later works as Dunham and Weinberg (195 ) and Perrucci (197 ), and perhaps achieved its apotheosis in Erving Goffman’s devastating portrait of mental hospitals as “total institutions,” which was published in 1961 and became one of the more enduring works of mid-twentieth century American sociology (Goffman 1961).
Goffman was trained at Chicago, and his research for Asylums, undertaken while he was on staff at the NIHM Laboratory of Socio-Environmental Studies, included a year of fieldwork at St Elizabeth’s Mental Hospital in Washington, D.C. But while in one sense rooted in the Chicago School tradition, Goffman’s work was in many ways Durkheimian in inspiration. In contrast to the symbolic-interactionist emphasis on the fluidity of social interaction, Goffman’s is a portrait of structural determinism. Mental hospitals resemble prisons and concentration camps, as well as monasteries, nunneries, and boarding schools. Life in such places is a product of their structural features, and their defects are not removable by any conceivable sets of reforms. Instead, life in a mental hospital tends inexorably to damage, to dehumanize, and to destroy.
Psychiatrists are ridiculed as members of a “tinkering trade” who induce their subordinates to stage elaborate rituals designed to show that they preside over a medical establishment devoted to humane care and cure, when in reality, they are little better than prison guards helping to generate the very pathologies they claim to treat. As he put it a decade later, mental hospitals were no more than “hopeless storage dumps trimmed in psychiatric paper.” As for the patient, he has been duped, suffering “dislocation from civil life, alienation from loved ones who arranged for the commitment, mortification due to hospital regimentation and surveillance, permanent post-hospital stigmatization. This has not merely been a bad deal; it has been a grotesque one” (Goffman 1971: 390).
From the late nineteen-sixties through the nineteen-eighties, the intellectual distance and even hostility between sociologists and psychiatrists often seemed to be growing. Within five years of the appearance of Asylums, the California sociologist Thomas Scheff had authored an in some ways still more radical assault on psychiatry, dismissing the medical model of mental illness and attempting to replace it with a societal reaction model, wherein mental patients were portrayed as victims – victims, most obviously, of psychiatrists (Scheff 1966). Noting that despite centuries of effort, “there is no rigorous knowledge of the cause, cure, or even the symptoms of functional mental disorders”, he argued that we would be better off adopting “a [sociological] theory of mental disorder in which psychiatric symptoms are considered to be labeled violations of social norms, and stable ‘mental illness’ to be a social role.” And “societal reaction [not internal pathology] is usually the most important determinant of entry into that role” (Scheff 1966: 7, 25, 28).
During the 1960s and 1970s, the societal reaction theory of deviance enjoyed a broad popularity and acceptance among many sociologists, and Scheff’s was one of the principal works in that tradition. But besides attracting derision and hostility from psychiatrists (Roth 1973), where they deigned to notice his work at all, it came under increasing criticism from within sociology on both theoretical (Morgan 1975) and empirical (Gove 1970; Gove and Howell 1974) grounds. In the face of an avalanche of well-founded objections, Scheff was eventually forced to back away from many of his more extreme positions, and by the time the third edition of his book appeared (Scheff 1999), most of its bolder ideas had been quietly abandoned. Labeling and stigmatization of the mentally ill have remained important subjects for sociologists, even if few would now argue that they have the etiological significance once attributed to them.
Though the skeptical claims of the labeling theorists have now been sharply curtailed, much of the sociological work being done on mental illness has retained its critical edge. Four major inter-related changes have occurred in the psychiatric sector in the past half century or so: the progessive abandonment of the prior commitment to segregative responses to serious mental illness, and the rundown of the state hospital sector; the collapse of psychoanalysis and its replacement by a renewed emphasis on the biological basis of mental illness; the psychopharmacological revolution; and the so-called neo-Kraepelinian revolution, the rise of the American Psychiatric Association’s Diagnostic and Statistical Manual to a position of overwhelming importance, not just to the practice of psychiatry in the United States, but to developments elsewhere in the world. Sociologists have played a crucial role in analyzing the sources and the impact of most of these changes, and sociological perspectives have spread and been highly influential among others attempting to make sense of these profoundly important developments.
Deinstitutionalization, for example, was initially presented as a grand reform, ironically just as the mental hospital had originally been (Rothman 1971; Scull 1979, 1993). From the mid-nineteen-seventies, however, a more skeptical set of perspectives emerged. Psychiatrists had assumed that the new generation of anti-psychotic drugs had been the main drivers of the expulsion of state hospital patients. A series of studies demonstrated the fallacy of this claim (Scull 1976, 1977; Lerman 1982; Gronfein 1985a). Others sought alternative explanations of the shift in social policy, and a series of studies began to suggest some of the defects of the new approach to the management of chronic mental illness (Kirk and Thierren 1975; Aviram, Syme and Cohen 1976; Windle and Scully 1976; Scull 1977, 1984; Rose 1979; Gronfein 1985b). The hegemony of the Diagnostic and Statistical Manual (DSM) began to attract attention, with critics examining both the processes by which the successive editions had been produced, and the intended and unintended effects of its widespread use (Kirk and Kutchins 1992; Kutchins 1997; Horwitz and Wakefield 2007; 2012) The sources and the impact of the psychopharmacological revolution drew increased interest, with attention paid to both the role of the pharmaceutical industry and changes in the intellectual orientation of the psychiatric profession (Healy 1997, 2002; Herzberg 2008).
All of this occurred in a context where much of the federal money which had once underwritten sociological work on mental illness had been sharply curtailed. In the nineteen-sixties and seventies, NIMH continued to define its research mission broadly, and to fund an extensive array of psychological and sociological research. Subjected to political pressures to direct funding towards the solution of social problems, the agency underwrote a broad array of studies on such topics as crime, drug and alcohol addiction, suicide, and even rape – all topics of some relevance to mental health issues, and all ensuring a continual flow of federal research money into the social sciences, but scarcely central concerns for those focused on psychiatric disorders. During the 1980s, however, this pattern of research funding abruptly altered. The Republican administration elected in 1982 ordered NIMH to redirect its funding priorities away from social-problem oriented research towards work more directly pertinent to the understanding of mental disorders (Kolb, Frazier, and Sivrotka 2000). Simultaneously, the intellectual center of gravity within psychiatry was shifting decisively away from psychoanalysis and a bio-social model of mental disorder and towards a biologically reductionist view of mental illness. The social, so far as most psychiatrists were concerned, went from being directly relevant to being at best marginal to their research. Thus, political pressures to avoid controversial and sensitive work on the sociological dimensions of mental disorder was reinforced by the demands of psychiatry for an increased focus on neuroscience and psycho-pharmacological research.
Scholars working on the sociology of mental illness thus now confront a very different research environment than the one that prevailed a quarter century ago. The range of intellectual and policy issues thrown up by the dramatic changes that have marked the mental health sector in the same period mean, however, that there is an abundance of challenging topics for the study of which sociological perspectives are indispensable. The range and scope of this Encyclopedia is vivid testimony to the intellectual vitality of the field, and will, one hopes, make a useful contribution to the next generation of sociological research on the cultural sociology of mental illness.
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Dunham, H.W. and Weinberg, S.K. (1960) The Culture of the State Mental Hospital Detroit: Wayne State University Press.
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Goffman, E. (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates Garden City, New York: Doubleday.
Goffman, E. (1971) “ The Insanity of Place,” Psychiatry 32: 357-390.
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Horwitz, A.V. and Wakefield, J.C. (2007) The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder New York: Oxford University Press.
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Rennie, T.A. and Srole, L. (1956) “Social Class Prevalence and Distribution of Psychosomatic Conditions in an Urban Population,” Psychosomatic Medicine 18: 449-456.
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