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Compare and contrast two of the five approaches to mental health & illness within Sociology. (social causation, social reaction (labelling theory), critical theory, social constructivism & social realism)
Mental Health Illness
The issue of mental health has long been an object of study for society, the psychiatric professions and sociology has similarly had a long tradition of offering theoretical insights into the phenomenon. Why this might be is open to debate and many of the key sociological theories in relation to mental health have in fact as much to say about the prevailing viewpoints within society and within professional bodies towards mental health as they do about those who suffer from mental health related problems (Cockerham, 1992). The two most radical of the sociological theories concerning mental health have been social reaction or labelling theories as well as that of social constructivism.
Both these theories examined within this essay offer a radical conception of mental health in comparison to what might be called the dominant medical and social views on mental health. However while both of these theories offer a radical view of mental health they differ substantially in the theoretical framework which they respectively utilize towards understanding mental health. These differences can be located in broader trends which have occurred within the discipline of sociology itself as a shift in the major theoretical traditions within the discipline, (Delanty, 1999). The two sociological theories examined are that of social reaction and social constructivism.
This critical theory emerged in the 1960s which in itself might serve to highlight the broader critical strands present within society when this theory was formulated. Labelling theory works from the simple premise that to define someone as mentally ill conveys upon them a stereotypical image which the person will then act. It drew its framework from the symbolic interactionism school of sociology so at its root this theory sought to examine the ways in which roles and actors interacted and played out within the drama of mental illness (Pilgrim and Rogers, 1999. Thus for labelling theory the relationship between the patient (or the individual defined as ill), family, medical professions and society generally is the determining factor for analysis in relation to mental illness.
For labelling theorists then the primary framework for analysing mental illness is to examine the twin concepts of primary deviance and secondary deviance. Primary deviance relates to things which might actually be wrong or actions or circumstances which involve actual rule breaking, (Pilgrim and Rogers, 1999) and for labelling theorists the most interesting item regarding this is the way those around sufferers rationalise and ignore this behaviour up unto a point, (Ineichen, 1979:11). Perhaps the most illustrative study of this phenomenon was the work of Yarrow, Schwartz, Murphy and Deasy (1955) which illustrated the various ways in which wives would dismiss strange behaviour up until a point was reached in terms of deviant behaviour.
However it is secondary deviance which labelling theory sees as the much more problematic of the two forms of deviance and it is here that the links also between the second of our theories examined are strongest. For labelling theorists secondary deviance has a number of critical factors. But simply put secondary deviance refers to those manifestations of symptoms which are not related in any way to the actual physical incidence. Thus we might say that the aetiology of secondary deviance is a function of the societal conditions surrounding the individuals rather than intrinsic conditions within the individual themselves. As Rosenham (1973) states The question of whether the sane can be distinguished from the insaneis a simple matter: do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environmentsin which observers find them (250).
In Rosenham's case where eight pseudo-patients gained entry into hospitals on the pretence of being insane to answer to this question lay firmly in the area of the observers. While popular at first with a number of studies finding the concepts expressed in the theory to be true in a number of famous studies labelling theory has not decreased in popularity with a number of major criticisms being levelled at the theory as a result of further investigation and continued studies
While labelling theory surmised that primary and secondary deviance were linked in that one will tend to lead to the other as a result of the ensuing interaction between the individual sufferer and those that label the sufferer this was not borne out by the research. In the case of Rosenham's study it was found that the label of deviant though at first an uncomfortable and disturbing experience did not persist for a great length of time with the pseudo-patients in the experiment, (Pilgrim and Rogers, 1999).
Another weakness expressed in labelling theory is the relationship between the stereotypical images of the insane believed to be held by the public. If society was to blame for labelling the insane then it would have been expected that the images lay people had conformed to the images of diagnosis, yet research has shown that this is not the case. Indeed lay perceptions to mental illness have been demonstrated to only marginally relate to the images associated with medical diagnosis, (Pilgrim and Rogers, 1999:18).
Labelling theory accepts then (and is a criticism of the theory) that a distinction can be drawn between physical disorders, primary deviance, and the ensuing reaction from society which causes secondary deviance. For the second theory we examine here the existence of both categories is dependent on society or in other words that mental illness exists as a completely subjective definition.
While referring to a broad range of social critiques across a many wide variety of disciplines it is perhaps best represented in terms of its comments on mental health by the works of the French theorist Michel Foucault. In particular his seminal work The Birth of the Clinic sets out the radical viewpoint with which social constructivism is associated. In this Foucault argues that insanity exists as a classificatory concept derived from the subjective description of medical knowledge. Or that the objectification of insanity occurred after as well as in tandem with the development of psychiatric knowledge, the insane developed as a problematised group which in turn led to strategies being developed to manage them, (Foucault, 1976)
Superficially then we can see many similarities between these two theories in that both see a critical role for society in the determination of the meaning of mental illness. The critical difference is that while for social reactionists and labelling theorists a division exists between primary deviance which has a physical locus and secondary deviance which arises out of societal causes whereas social constructivists assign the loci of mental health strictly to the social environment. It does this through utilising the theoretical framework of discourses, thus the subjectivity of being mad is defined through the objectifying process of psychiatric or medical knowledge generally (Pilgrim and Rogers, 1999).
While many works recently have adopted social constructivist viewpoints in relation to medical knowledge it is Foucault's works which are the best known and also which have been the most influential in developing this theoretical viewpoint. Foucault's work was in particular concerned with how the shifting conceptions of what madness meant to society led to the development of a discrete set of knowledges which pathologise mental states according to a classificatory system related to madness and what were the strategies which developed as a result of this knowledge towards the control and management of the insane (Foucault, 1972, 1976).
This concept has had radial implications for a consideration of mental health and how it is defined in as well as by society. This theoretical framework can be seen thusly to criticise not only psychiatric practice but also psychiatric knowledge and even more critically the processes through which psychiatric knowledge is generated. Indeed from a social constructivist viewpoint it is the very construction of knowledge which leads to the boundaries and categories which delineates and determines who it is we call insane and indeed what it is that makes them insane for society.
Perhaps the biggest criticism we can make of the social constructivist viewpoint is the lack of a normative basis to its analysis. While the critique may be valid social constructivist theories can be distinctly vague about resistances to the all powerful discourses which they describe and analyse. Similarly the ability to formulate social policies arising out of the critique may similarly be limited (Rogers and Pilgrim, 2001: 175). A secondary point and one which we have already made in relation to labelling theory is that perhaps social constructivism deconstructs too much certain incidences of mental illness, perhaps there are some illnesses which in their aetioloigcal sense reveal themselves to be indeed physical manifestations of what we might actually be able to call a disorder (Zinberg, 1970).
Thus from this analysis we can see the close links as well as the clear differences between these two theories. While both are radical in their outlook we can argue that social constructivism has even been more radical. Similarly while social reaction theories have fallen out of favour along as well it must be noted as symbolic interactionsim in general social constructivist theories have been and continue to be hugely influential not only in relation to mental illness but to a broad range of social scientific disciplines and social issues.
Cockerham, W. C. (1992); Sociology of Mental Disorder; 3rd Ed., Simon and Schuster Co.; New Jersey US
Delanty, G. (1999); Social Theory in a Changing World, Polity Press, Malden US
Foucault, M. (1976); The Archaeology of Knowledge, Tavistock, London UK
Foucault, M. (1976); The Birth of the Clinic, Tavistock, London UK
Ineichen, B. (1979); The Social Structure of Modern Britain: Mental Illness, Longman, London UK
Pilgrim, D. and Rogers, A. (1999); A Sociology of Mental Illness, 2nd Ed., Open University Press, NY US
Rogers, A. and Pilgrim, D. (2001); Mental Health Policy in Britain, Palgrave, Basingstoke UK
Rosenham, D.L. (1973); 'On Being Sane in Insane Places'; Science, Vol 179 Jan
Yarrow, M., Schwartz, C, Murphy, H. and Deasy, L. (1955); 'The Psychological Meaning of Mental Illness in the Family', Journal of Social Issues, Vol 11 No. 12
Zinberg, N. (1970); 'The Mirage of Mental Health', British Journal of Sociology, Vol. 21 No. 3