SOC 2.3

"LEARNING OBJECTIVES After reading this chapter 7, students should be able to:•Assess how ethnicity, gender, social class, social stress, and social capitalaffects mental illness.•Compare the medical and sociological models of mental illness.•Understand how medical and social ideas about mental illness have evolvedover time.•Offer a sociological description of the experience of living with mental

"As Norah Vincent’s story suggests, mental illness is a social as well as a psy-chiatric condition, and mental hospitalization has social as well as psychiatric con-sequences. We begin this chapter by considering the extent and distribution ofmental illness. We then examine contrasts between the medical model of mentalillness, which views mental illness as an objective reality, and the sociologicalmodel, which views mental illness as largely a social construction. Finally, welook at how social forces and values have affected both the history of treatmentand the experiences of those who live with mental illness.THE EPIDEMIOLOGY OF MENTAL ILLNESSThe importance of understanding mental illness becomes clearer when we realizehow many people are affected. The following section discusses research on theextent, distribution, and causes of mental illness.The Extent of Mental IllnessSince the 1920s, social scientists have tried to ascertain the extent of mental ill-ness. These researchers essentially have adopted medical definitions of mental ill-ness (which, as we will see later in this chapter, are problematic). However,whereas doctors and other clinicians have focused on how biological or psycho-logical factors can foster mental illness, social scientists have focused on howsocialfactors can do so.Over the years, researchers using a variety of methods have reached twoconsistent conclusions regarding the extent of mental illness. First, all societies,from simple to complex, include some individuals who behave in ways consid-ered unacceptable and incomprehensible (Horwitz, 1982:85–103). Second,symptoms of mental disorder are fairly common. According to the NationalComorbidity Survey Replication, the largest national survey on the topic basedon arandom sample(Kessler et al., 2005a), during the course of a year approx-imately 31 percent of working-age adults experience a diagnosable mental illness,with 20 percent experiencing a moderate or severe disorder. The most commonillnesses are major depression and problems with alcohol use, reported by 17 and13 percent, respectively. These estimates, however, are probably high becausethey are based on reports of symptoms taken out of context (Horwitz, 2002,2007). When an individual reports that he is extremely sad, survey researcherscan’t tell whether the sadness was caused by clinical depression or financialproblems. Nor can researchers tell whether a woman who reports losingweight has done so because of depression or because she wanted to fit into her" "Social Stress and Mental IllnessAlthough mental illness is common, it does not burden all social groups equally.So why do some social groups experience more mental illness than others do?For many sociologists, the answer lies in their different levels of social stress.In the past, sociologists interested in the link between mental illness andstress largely focused on theacutestresses oflife events, such as divorce, losinga job, or a death in the family. Researchers looked not only at the sheer numberof life events individuals experienced but also at themeaninglife events have forpeople and theresourcesindividuals have for dealing with those life events. Forexample, an unplanned pregnancy means something quite different to an unmar-ried college student from a poor family than it does to a married, middle-classhousewife.Similarly, some individuals have resources that can reduce the stresses of lifeevents (such as money, social support networks, and psychological coping skills),whereas others lack such resources (Ensel and Lin, 1991; Lennon and Limonic,2010; Turner and Brown, 2010). For example, a person whose marriage fails butwho has enough income to maintain his or her current lifestyle, close friends toprovide companionship and social support, and good stress management skillswill probably experience less stress than will someone whose economic standingplummets after divorce, who has few friends, and who responds to stress bydrinking.As we saw in Chapter 2, recent research finds thatchronicstress is moreimportant than acute stress for predicting poor physical health. Similarly,researchers have shown that chronic stresses affect mental health more than doacute stresses such as life events (Turner and Avison, 2003). Much research inthis field now focuses on how exposure to chronic social stress may explain eth-nic, gender, and social class differences in rates of mental illness.Ethnicity, Gender, Social Class, and Rates of Mental IllnessEthnicity, gender, and social class all affect rates of mental illness, as Table 7.1summarizes. The rest of this section explains these effects." "The Impact of Ethnicity: Stress EffectsResearchers have uncovered few sig-nificant ethnic differences in rates of schizophrenia or other major mental ill-nesses. However, for still unexplained reasons, African Americans seemlesslikely than do whites to develop anxiety or mood disorders. Nevertheless,African Americans aremorelikely—especially if they are poor—to report psycho-logical distress, which overlaps with but is not the same as diagnosable mentalillness (Kessler et al., 2005a). Researchers theorize that psychological distressamong African Americans results from the chronic daily stresses of living withracism. This would explain why, for example, wealthier African Americans—who can use their income to shield themselves somewhat from the effects ofracism—experience less stress than do lower income African Americans (Kesslerand Neighbors, 1986; Turner and Avison, 2003).Little recent research is available on psychological distress among other USminority groups. However, Hispanic Americans are less likely to develop anxietydisorders, mood disorders, or substance abuse problems (Kessler et al., 2005a).Importantly, the rate of mental disorders among new immigrants from Mexicois half that of US-born Mexican Americans, but those rates converge after immi-grants have been in the United States for more than a decade (Vega et al., 1998).Researchers hypothesize that Mexican culture’s strong emphasis on extendedfamilies protects immigrants from mental illness by offering social support andthus reducing chronic stress among persons who are single, childless, less edu-cated, or employed in low-prestige jobs. As Mexicans integrate into Americanculture, they lose these protections.The Impact of Gender: Socialization EffectsThe impact of gender on men-tal illness is at least as complex as the impact of ethnicity. Most mental illnessesare equally common among men and women. However, men have higher ratesof schizophrenia, substance abuse, and impulse control disorders (such as com-pulsive gambling or chronic violence), whereas women have higher rates of anx-iety disorders and of mood disorders (such as depression) (Aleman, Kahn, andSelten, 2003; Kessler et al., 2005a).These differences in mental illness parallel differences in gender roles. Con-sistently, men display higher rates of disorders linked to violence. As a result,some researchers hypothesize that these forms of mental illness occur whenmen become“oversocialized”to their gender roles. For example, a young manwho fails to plan ahead, shows“reckless disregard”for safety, and gets into fightsoften, and who before the age of 15 often bullied others, got into fights, orskipped school, would meet the criteria for diagnosis with“antisocial personalitydisorder.”Yet these behaviors more or less parallel expectations within lower-class communities for how young men should act. Within these communities,men who meet these expectations are typically considered dangerous, but notmentally ill, because their behavior is comprehensible. Although they might belabeled criminal, they are unlikely to be labeled mentally ill unless they somehowcome to the attention of doctors from outside their communities.Similarly, many sociologists hypothesize that depression results when tradi-tional female roles cause chronic stress by reducing women’s control over their" "lives (Horwitz, 2002:173–179). Research has found that rates of depression areconsiderably higher among women with the least control over their lives: non-working women and married mothers. By the same token, depression is espe-cially common among men who have less power than their wives do, havelittle control over their work, or lose their jobs.The Impact of Social Class: Social Stress or Social Drift?Of all the demo-graphic variables researchers have investigated, social class shows the strongestand most consistent impact on mental illness. As social class goes up, the rate ofboth diagnosable mental illness and psychological distress goes down (Eaton andMuntaner, 1999; Kessler et al., 1994). But does lower social class status causemental illness, or does mental illness cause lower social class? In other words,do the social stresses associated with lower-class life lead to greater mental disor-der, or do those who suffer from mental disorder drift downward into the lowersocial classes? These two theories are referred to associal stressversussocialdrift, respectively.Researchers interested in social class have focused primarily on schizophre-nia, the disease that shows the most consistent relationship to social class; studieshave found that schizophrenia and related disorders occur two to five times moreoften among those who have not graduated from college compared with thosewho have. Those who favor the social drift argument have shown that, forexample, at first admission to a mental hospital, patients diagnosed with schizo-phrenia hold jobs lower in social class than one would expect given their familybackgrounds. This suggests that mental problems caused these individuals to driftdownward in social class (Eaton and Muntaner, 1999).Most research, however, suggests that social stress better explains the linkbetween social class and mental illness (Aneshensel, 2009; Schwartz and Meyer,2010). For example, those diagnosed with schizophrenia are more likely thanothers to have grown up in lower-class homes and to have held stressful, noisy,hazardous, and physically uncomfortable jobs evenbeforetheir first admissions tomental hospitals (Link, Lennon, and Dohrenwend, 1993; Muntaner et al., 2004).Recently, this theory has been vividly reinforced by reports of extremely highrates of mental illness among returning war veterans, most of whom comefrom poor or working-class families (seeContemporary Issues: Invisible Wounds ofWarfor more details).Social Capital and Mental IllnessAs Chapter 3 explained,social capitalrefers to the resources available to anindividual through his or her social network. Social capital is more commonamong those with higher social class but affects mental health across ethnic,class, and gender lines (Song, 2011). Not surprisingly, those with more socialcapital typically report less psychological distress. For example, people in theirfifties and sixties often have excellent social capital: extensive connections tofriends, neighbors, and relatives who have garnered a wide variety of resourcesover many years. This may partly explain why people in this age range report less" "history of medical treatment for syphilis, the disease that first demonstrated thepower of medicine to control mental illness and that in many ways establishedthe frame through which doctors would understand all mental illnesses.Since the fifteenth century, doctors had recognized syphilis as a discrete dis-ease. Because of its mild initial symptoms, however, only in the late nineteenthcentury did doctors realize the full damage syphilis can inflict on the nervoussystem, including blindness, deformity, insanity, and death. Unfortunately, doc-tors could do little to help those with syphilis. The best available treatment con-sisted, essentially, of poisoning patients with arsenic and other heavy metals inthe hopes that these poisons would kill whatever had caused the disease beforethey killed the patients.In 1905, scientists first identified the bacteriumTreponema pallidumas thecause of syphilis. Five years later, Paul Ehrlich discovered the drug Salvarsan asa cure for syphilis. Salvarsan, an arsenic derivative, was the first drug that success-fully targeted a specific microorganism. As such, it opened the modern era ofmedical therapeutics. After this point, those who sought early treatment forsyphilis could expect a complete cure, whereas those who put off treatmentrisked irreversible neurological damage and a horrible death.The history of Salvarsan and syphilis provided ideological support for amedical model of mental illness. This medical model is composed of fourassumptions about the nature of mental illness (Scheff, 1984):1. Objectively measurable conditions define mental illness, in the same waythat the presence of a specific bacterium defines syphilis.2. Mental illness stems largely or solely from something within individual psy-chology or biology, even if doctors (such as those who studied syphilisbefore 1905) don’t yet know its sources.3. Mental illness, like syphilis, will worsen if left untreated but may diminish ordisappear if treated promptly by a medical authority.4. Treating mental illness, like treating syphilis, rarely harms patients, so it issafer to treat someone who might really be healthy than to refrain fromtreating someone who might really be ill.The Sociological Model of Mental IllnessThe sociological model of mental illness questions each of these assumptions (seeKey Concepts: Models of Mental Illness). Perhaps most important, sociologists arguethat definitions of mental illness, like the definitions of physical illness and dis-ability discussed in Chapters 5 and 6, reflect subjective social judgments morethan objective scientific measurements of biological problems.What do we mean when we say someone is mentally ill? Why do we diag-nose as mentally ill people as disparate as a teenager who uses drugs, a womanwho hears voices, and a man who tries to kill himself? According to sociologistAllan Horwitz (1982), behavior becomes labeled mental illness when persons inpositions of power consider that behavior both unacceptable and inherently" "incomprehensible. In contrast, we tend to define behavior as crime when weconsider it unacceptable but comprehensible; we don’t approve of theft, butwe understand greed as a motive. (The judgment of“not guilty by reason ofinsanity”falls on the border between crime and mental illness.) Similarly, wemight not understand why physicists do what they do, but we assume thatthose with appropriate training find their behavior comprehensible.According to Peggy Thoits (1985), behavior leads to the label of mentalillness when it violatescognitive norms, performance norms,orfeelingnorms. Someone who thinks he is Napoleon Bonaparte, for example, breakscognitive norms (i.e., norms regarding how a person should think), and some-one who can’t hold a job breaks norms regarding proper role performance.Thoits argues that the last category—breaking feeling norms—accounts formost behavior labeled mental illness. Feeling norms refer to socially definedexpectations regarding the“range, intensity, and duration of feelings that areappropriate to given situations”and regarding how people should expressthose feelings (Thoits, 1985:224). For example, laughing is highly inappropriateat a Methodist funeral but perfectly acceptable at an Irish wake, and feeling sadthat your pet cat died is considered reasonable for a few days but unreasonableafter a year.Different social groups consider different behaviors comprehensible andacceptable. The friends of a drug-using teenager, for example, might considerdrug use a reasonable way to reduce stress or have fun. Their views, however,have little impact on public definitions of drug use. Similarly, members of onechurch might consider a woman who reports talking to Jesus a saint, whereasmembers of another church would consider her mentally ill. The woman’s fatewill depend on how much power these opposing groups have over her life. Thedefinition of mental illness, then, reflects not only socially accepted ideas regard-ing behavior but also the relative power of those who hold opposing ideas." "Researchers who use this sociological definition of mental illness don’t meanto imply that emotional distress does not exist or that people don’t feel real painwhen they can’t meet social expectations for thought, behavior, or emotions.Nor do these researchers mean to imply that biology has no effect on behavioror thought. They do, however, question the purpose and consequences of usingmedical language to describe such problems, and question why we label certainbehaviors and individuals, but not others.Not all sociologists raise these questions, however. Many, especially thoseworking in health care settings and inepidemiology, use asociologyinmedicineapproach and use essentially medical definitions of mental illness intheir research and writing. Nevertheless, sociologists are united in assuming thatmental illness, like physical illness and disability, stems at least partially from sociallife rather than solely from individual psychology or biology.The Problem of DiagnosisThe sociological model of mental illness gains credibility when we look at researchon the problems with psychiatric diagnosis. These problems became a politicalembarrassment for psychiatrists (medical doctors who specialize in treatingmental illness) after a famous experiment by psychologist David Rosenhan(1973). Rosenhan and seven of his assistants had presented themselves to 12 mentalhospitals and complained of hearing voices but otherwise had acted normally.The hospitals diagnosed all eight“pseudopatients”as mentally ill and admittedthem for treatment. After they were admitted, all behaved normally, leading30 percent of the otherpatientsto identify them as frauds. Thestaff, however,never noticed anything unusual about these pseudopatients. It took an averageof 19 days for them to win their release, with their symptoms declared“inremission.”When these results were published, psychiatrists objected vociferously thatthe results were some sort of fluke. In response, Rosenhan agreed to send pseu-dopatients to another hospital and challenged the staff at that hospital to identifythe pseudopatients. During the three months of the experiment, the staff identi-fied 42 percent of their new patients as pseudopatients even though Rosenhanreally had not sent any!These two experiments vividly demonstrate the subjective nature of psychiat-ric diagnosis and its susceptibility to social expectations. Within the context of amental hospital, staff members quite reasonably assume patients are ill and interpreteverything patients do accordingly. When, for example, one bored pseudopatientbegan taking notes, a worker officially recorded this“note-taking behavior”as asymptom. Conversely, when staff members expected to find pseudopatients, theyinterpreted similar behaviors as signs of mental health.The problems with diagnosis are particularly acute when a therapist andpatient don’t share the same culture. With the rise in immigration to the UnitedStates over the past generation, doctors increasingly must diagnose and treatpatients whose symptoms don’t appear in Western textbooks (Goleman, 1995).For example, a common symptom of psychological problems in the United" "States is debilitating fear of being embarrassed by one’s body, whereas a commonsymptom in Japan is debilitating fear (known astaijin kyofusho) that one’s bodywill embarrasssomeone else. Similarly, a common symptom of mental illness inthe United States is fear of abduction by aliens, whereas a common symptom inMalaysia iskoro, the intense fear that one’s penis and testicles will recede intothe body and somehow cause one’s death. Current guidelines of the AmericanPsychiatric Association (APA) recommend that psychiatrists consider cultural andethnic factors in their work and require training programs to cover cross-culturalissues.The Politics of DiagnosisOver the years, psychiatrists have worked to reduce problems with diagnosis byrefining the definitions of illnesses in theDiagnostic and Statistical Manual ofMental Disorders (DSM), first published by the APA in 1952. Virtually all psy-chiatrists use this manual for assigning diagnoses, as do most other clinicians,because insurers usually require aDSMdiagnosis before they will reimburse clin-icians for care.TheDSMand the subsequentDSM-II, published in 1968, instructed clini-cians to reach diagnoses based on the clinicians’inferences about such intrapsy-chic processes as defenses, repression, and transference. Because clinicians can’tmeasure these processes, the same behavior often elicited quite different diagno-ses from different clinicians (Helzer et al., 1977).Partly because of these problems, in 1974, the APA announced its decisionto revise theDSM-II(Spitzer, Williams, and Skodol, 1980). Ironically, althoughthe resultingDSM-III, published in 1980, was designed to quiet questions aboutthe ambiguities of psychiatric diagnosis, it instead illuminated those ambiguitiesbecause its writing became an overtly political battle, involving active lobbyingby both professional and lay groups (Grob and Horwitz, 2009). This battlerevealed wide differences among clinicians regarding what behaviors signifiedmental illness, what caused those behaviors, who should treat them, and howthey should be treated.To encourage support for theDSM-IIIand to avoid open political battlesamong psychiatrists, its authors decided to stress symptomatology and avoid dis-cussing either causation or treatment (Kirk, 1992). In addition, to increase theodds that clinicians would use theDSM-III, the authors described the variousdiagnoses based not on available research, but rather on the consensus amongpracticing psychiatrists. These two strategies, they hoped, would produce awidely used and highly reliable document.Reliabilityrefers to the likelihoodthat different people who use the same measure will reach the same conclu-sions—in this case, that different clinicians, seeing the same patient, wouldreach the same diagnosis. Yet even this modest goal was not achieved becausestudies continue to find high rates of disagreement over diagnosis (Kirk, 1992;Mirowsky and Ross, 1989). Moreover, reliability in the absence of validity isnot particularly useful.Validityrefers to the likelihood that a given measureaccurately reflects what those who use the measure believe it reflects—in this" "case, that persons identified by theDSM-IIIas having a certain illness actuallyhave that illness. As Phil Brown (1990:393) notes,“Anyone can achieve...reli-ability by teaching all people the‘wrong’material, and getting them to all agreeon it.... The witch trials [of earlier centuries] showed a much higher degree ofinterrater reliability than any DSM category, yet we would not impute anyvalidity to those social diagnoses.”Despite all of these problems, theDSM-IIIand the subsequentDSM-IVgained great support among clinicians because they served a variety of politicalneeds (Horwitz, 2002). By stressing (even if inaccurately) the“objective”natureof diagnosis, clinicians were able to gain respect in the medical world, access toreimbursement from insurance companies, and funding from agencies that spon-sor research. By assigning discrete diagnoses to all the different client groups andcombinations of symptoms treated by different types of clinicians, they couldgain widespread acceptance of the system from both clinicians and clients; theDSM-IVcontains almost 400 different diagnoses. Finally, a system that empha-sized diagnosis and symptoms, rather than underlying causes of illness, bothstemmed from and was reinforced by the increasing reliance on drugs as themain treatment for mental illness.TheDSM-Vwas published in 2013. As with previous editions, critics arguethat evidence for the validity of diagnostic categories remains limited and that thenew edition will lead to further medicalization and overtreatment of everydaylife struggles (Frances, 2012). For example, unlikeDSM-IV,DSM-Vdefinesordinary forgetfulness among older adults, grieving for more than two monthsafter a loved one dies, and what many would describe as“temper tantrums”asnew forms of mental illness. Importantly, criticism of this new edition has comefrom within as well as outside of psychiatry.A HISTORY OF TREATMENTThe history of treatment for mental illness further reveals the role social valuesplay in medical responses to problematic behavior. In this section, we trace thetreatment of mental illness from the prescientific era to the present.Before the Scientific EraAlthough the concept of mental illness is relatively new, all societies throughouthistory have had individuals whose behavior set them apart as unacceptably andincomprehensibly different. However, premodern societies more often couldfind informal ways of coping with such individuals (Horwitz, 1982). First, pre-modern societies could offer acceptable, low-level roles to those whose thoughtpatterns and behaviors differed from the norm. Second, because work roles rarelyrequired individuals to function in highly structured and regimented ways, manytroubled individuals could perform at marginally acceptable levels. Third, in pre-modern societies, work occurred within the context of the family, whether at" "home or in fields or forests. As a result, families could watch over those whoseemotional or cognitive problems interfered with their abilities to care for them-selves. These three factors enabled families tonormalizemental illness byexplaining away problematic behavior as mere eccentricity. As a result, unlessindividuals behaved violently or caused problems for civil authorities, their fami-lies and communities could deal with them informally.In some cases, however, individuals behaved too unacceptably or incompre-hensibly for their communities to normalize. In these cases and as is true with allillnesses (as described in Chapter 5), communities needed to find explanations tohelp them understand why such problems struck some people and not others.Such explanations helped to make the world seem more predictable and safe byconvincing the community that such bad things would never happen to“goodpeople”like themselves.Until the modern scientific age, societies typically viewed disturbing behavioras a punishment for sin or for violating a taboo; a sign that the afflicted individualwas a witch; or a result of evildoing by devils, spirits, or witches. Therefore, theyassigned treatment to religious authorities—whether shamans, witch doctors, orpriests—who relied on prayer, exorcism, spells, and treatments such as bloodlet-ting or trepanning (drilling a hole in the skull to let“bad spirits”out). Religiouscontrol of socially disturbing behavior reached a spectacular climax with thewitchcraft trials of the fifteenth to seventeenth centuries, during which religiousauthorities brutally killed at least 100,000 people, including some we would nowlabel mentally ill (Barstow, 1994).As a capitalist economy began to develop, both religious control and infor-malsocial controlbegan to decline (Horwitz, 1982; Scull, 1977). Under capi-talism, work moved from home and farm to workshops and factories, makingit more difficult for families to care informally for problematic relatives. In addi-tion, a capitalist economy could less readily absorb those whose productivitycould not be scheduled and regimented. At the same time, widespread migrationfrom the countryside to cities weakened families and other social supportsystems, as did migration from Europe to the United States in subsequent centu-ries. Meanwhile, other changes in society weakened religious systems of socialcontrol.These changes fostered a need for new, formal institutions to address men-tal illness. By the end of the eighteenth century, however, only a few hospitalsdevoted to treating people with mental illnesses existed along with a few private“madhouses”run by doctors for profit. Instead, most of those we wouldnow label mentally ill were housed with poor people, people with disabilities,and criminals in the newly opened network of publicalmshouses,orpoorhouses.Conditions in both almshouses and madhouses were generally miserable, butthey were especially bad for those considered mentally ill. Doctors and the publictypically believed that persons with mental illness were incurable and were essen-tially animals. As a result, institutions treated people with mental illnesses likeanimals—chaining them for years to basement walls or cells, often without cloth-ing or proper food, and beating them if they caused problems" "The Rise and Decline of Moral TreatmentBy the late eighteenth century, however, attitudes toward persons with mentalillness began to moderate (Scull, 1989:96–117). In place of punishment andwarehousing, reformers proposedmoral treatment: teaching individuals tolive in society by showing them kindness, giving them opportunities to workand play, and in general treating mental illness more as a moral than a medicalissue. The stunning successes that resulted convinced the public that mental ill-ness was curable. The first American hospital designed to provide moral treat-ment, the Friends’(or Quakers’) Asylum, was founded in 1817.Despite this strong beginning, moral treatment in the end could not com-pete with medical models of mental illness (Scull, 1989:137–161). Because thosewho promoted moral treatment continued to use the language of medicine, talk-ing of illnesses and cures, medical doctors could argue successfully that only theyshould control this field. In addition, because moral treatment required onlykindness and sensitivity, which theoretically any professionals could offer, noprofessional group could claim greater expertise than doctors. As a result, by1840, doctors largely had gained control over the field of mental illness both inthe United States and Europe" "As care gradually shifted from laypersons to doctors, custodial care began toreplace moral treatment. This shift reflected the growing belief that illness wasgenetic and untreatable, as well as the public’s greater interest incontrollingpeoplewith mental illnesses—especially if they were poor, nonwhite, or immigrant—than intreatingthem.By the 1870s, moral treatment had been abandoned. Yet the number ofmental hospitals continued to grow exponentially (Rothman, 1971). Historiansrefer to this change, and the similar but earlier developments in Europe, as theGreat Confinement.The Great Confinement drew energy from the well-meaning efforts of refor-mers to close down the brutal almshouses and to provide facilities specificallydesigned to care for people with mental illnesses instead of warehousing themwith criminals, persons with disabilities, and poor people (Sutton, 1991). Becauseno agreed-upon definitions of mental illness existed, however, families and com-munities found it relatively easy to move the troublesome, poor, old, or sick intothe newly established mental hospitals (Sutton, 1991). As a result, most of thoselabeled mentally ill continued to find themselves housed with others whom soci-ety had rejected. The only difference was that instead of residing in institutionsfilled with a varied group of marginalized individuals, they now lived in largeinstitutions officially devoted to the“care”of people with mental illnesses.Freud and PsychoanalysisBy the beginning of the twentieth century, then, doctors controlled the mentalillness field. Yet doctors were deeply divided between those who assumed men-tal illness stemmed from psychological causes and those who assumed it had bio-logical causes.This split grew wider with the rise of Freudian psychiatry. According to Sig-mund Freud, a Viennese doctor, to become a mentally healthy adult, one had torespond successfully to a series of developmental issues. Each issue occurred at aspecific stage, with each stage linked to biological changes in the body andinvested with sexual meanings. For example, Freud believed that during thephallic stage (between about ages 3 and 6) boys naturally begin noticing genitalia,experiencing sexual attraction toward their mothers, and therefore viewing theirfathers as rivals. To become healthy adults, he argued, boys had to conclude thatgirls lack penises because their fathers castrated them after some wrongdoing.To avoid the same fate, boys must abandon their attraction for their mothersand instead pursue their fathers’love by adopting their fathers’values. Throughthis process, Freud argued, boys develop a strong internal sense of morality—something that girls, lacking penises, can never do.Freud based this theory on his interpretations of the lives and dreams of hisupper-middle-class patients; no scientific data underpin this theory. Lookingback at this theory from the present, it is hard to comprehend how anyonecould have believed in such notions. Yet the theory remained popular for dec-ades, undoubtedly because it both reflected and supported popular ideas aboutmen’s superior bodies, intellect, and moral virtues" "For those who accepted Freud’s theory, the only way to cure mental illnesswas to help patients resolve their developmental crises. To do so, Freud and hisfollowers relied on psychoanalysis, a time-consuming and expensive form of psy-chotherapy geared to patients without major mental illnesses. In psychoanalysis,patients recounted their dreams and told a (usually silent) therapist whatevercame to mind for the purpose of recovering hidden early memories and under-standing their unconscious motivations.Because psychoanalysis was so costly, most mental patients instead receivedfar cheaper physical interventions such as electroconvulsive (shock) therapy orlobotomies (Valenstein, 1986). Neither therapy received scientific testing beforebecoming popular and both could cause brain damage (Valenstein, 1986). At anyrate, therapy of any sort occupied only a minuscule proportion of patients’timein mental hospitals. Instead, patients spent their days locked in crowded wardswith little other than radios or, later, televisions to ease their boredom.The Antipsychiatry CritiqueBy the middle of the twentieth century, mental hospitals had become a huge andlargely unsuccessful system (Mechanic, 1989). Patients with mental illnessesoccupied half of all hospital beds in the United States. Virtually all (98%) werekept in public mental hospitals; insurance rarely covered mental health care, soprivate hospitals had no interest in the field. At their peak in 1955, public mentalhospitals held 558,000 patients, for an average of eight years. Most were invol-untarily confined and involuntarily treated, often with lobotomies as well asdrugs that kept them highly sedated.Beginning in the 1960s, however, many challenged this system, as the civilrights, antiwar, and feminist movements all promoted both individual rights andquestioning authority. These ideas contributed to a growing critique of mentalhealth treatment by sociologists, psychologists, and even some psychiatrists suchas R. D. Laing (1967).One of the most powerful critiques of large mental institutions appeared in aclassic study by sociologist Erving Goffman (1961). Goffman’s work fell withinthe tradition ofsymbolic interactionismtheory. According to this theory,individual identity develops through an ongoing process in which individualssee themselves through the eyes of others and learn through social interactionsto adopt the values of their community and to measure themselves againstthose values. In this way, aself-fulfilling prophecyis created, through whichindividuals become what they are already believed to be. So, for example, chil-dren who constantly hear that they are too stupid to succeed in school mightconclude that it is senseless to attend classes or study. As a result, they fail inschool, thus fulfilling the prophecies about them.Goffman used symbolic interactionism theory to analyze mental hospitalsand the experiences of mental patients. He pointed out that mental hospitals,like the military, prisons, and monasteries, weretotal institutions—institutionswhere a large number of individuals lead highly regimented lives segregated fromthe outside world. Goffman argued that these institutions necessarily produced" "mortificationof the self. Mortification refers to a process through which a per-son’s self-image is damaged and is replaced by a personality adapted to institu-tional life.Several aspects of institutional life foster mortification. Persons confined tomental hospitals lose the supports that usually give people a sense of self. Cut offfrom work and family, these individuals’only available role is that of patient.That role, meanwhile, is amaster status—a status considered so central thatit overwhelms all other aspects of individual identity. Within the mental hospi-tal, a patient is viewed solely as a patient—not as a mother or father, husband orwife, worker or student, radical or conservative. According to Goffman’s obser-vations, and as in Rosenhan’s (1973) experiment, all behavior becomes inter-preted through the lens of illness. In addition, because each staff member mustmanage many patients, staff members lack the time to individualize care. Inthese circumstances, patients typically lose the right to choose what to wear,when to awaken or sleep, when and what to eat, and so on. Moreover, all ofthese activities occur in the company of many others. Individuals thus not onlyexperience a sense of powerlessness but also can lose a sense of their identity—their desires, needs, and personalities—in the mass of others. As a result, patientsexperiencedepersonalization—a feeling that they no longer are fully human,or no longer are considered fully human by others. At the same time, the hier-archical nature of mental hospitals reinforces the distinctions between inmatesand staff and constantly reminds all parties of the gulf between them. Conse-quently, patients can avoid punishment and eventually win release only by sti-fling their individuality and accepting the institution’s beliefs and rules. Theseforces producing mortification are so strong that even Rosenhan’s pseudopati-ents—knowing themselves sane and hospitalized only briefly—experienceddepersonalization.Implicit in Goffman’s work is the idea that mental hospitals may be one ofthe worst environments for treating mental problems. Later research supports thisconclusion. A review of tencontrolledstudies on alternatives to hospitalization,including halfway houses, day care, and supervised group apartments, found thatall could boast equal or better results than those of traditional hospitalization, asmeasured by subsequent employment, reintegration into the community, life sat-isfaction, and extent of symptomatology (Kiesler and Sibulkin, 1987).DeinstitutionalizationBy the time the antipsychiatry critique appeared, the Great Confinement alreadyhad begun to wane. Beginning in 1955, the number of mental hospital inmatesdeclined steadily as treatment shifted frominpatientcare (in hospitals) tooutpatientcare. This process of moving mental health care away from largeinstitutions, known asdeinstitutionalization, gained further support duringthe 1970s, as mental patients successfully fought in the courts against involuntarytreatment, against hospitals that provided custodial care rather than therapy,and for the right to treatment in the“least restrictive setting”appropriate fortheir care" "mortificationof the self. Mortification refers to a process through which a per-son’s self-image is damaged and is replaced by a personality adapted to institu-tional life.Several aspects of institutional life foster mortification. Persons confined tomental hospitals lose the supports that usually give people a sense of self. Cut offfrom work and family, these individuals’only available role is that of patient.That role, meanwhile, is amaster status—a status considered so central thatit overwhelms all other aspects of individual identity. Within the mental hospi-tal, a patient is viewed solely as a patient—not as a mother or father, husband orwife, worker or student, radical or conservative. According to Goffman’s obser-vations, and as in Rosenhan’s (1973) experiment, all behavior becomes inter-preted through the lens of illness. In addition, because each staff member mustmanage many patients, staff members lack the time to individualize care. Inthese circumstances, patients typically lose the right to choose what to wear,when to awaken or sleep, when and what to eat, and so on. Moreover, all ofthese activities occur in the company of many others. Individuals thus not onlyexperience a sense of powerlessness but also can lose a sense of their identity—their desires, needs, and personalities—in the mass of others. As a result, patientsexperiencedepersonalization—a feeling that they no longer are fully human,or no longer are considered fully human by others. At the same time, the hier-archical nature of mental hospitals reinforces the distinctions between inmatesand staff and constantly reminds all parties of the gulf between them. Conse-quently, patients can avoid punishment and eventually win release only by sti-fling their individuality and accepting the institution’s beliefs and rules. Theseforces producing mortification are so strong that even Rosenhan’s pseudopati-ents—knowing themselves sane and hospitalized only briefly—experienceddepersonalization.Implicit in Goffman’s work is the idea that mental hospitals may be one ofthe worst environments for treating mental problems. Later research supports thisconclusion. A review of tencontrolledstudies on alternatives to hospitalization,including halfway houses, day care, and supervised group apartments, found thatall could boast equal or better results than those of traditional hospitalization, asmeasured by subsequent employment, reintegration into the community, life sat-isfaction, and extent of symptomatology (Kiesler and Sibulkin, 1987).DeinstitutionalizationBy the time the antipsychiatry critique appeared, the Great Confinement alreadyhad begun to wane. Beginning in 1955, the number of mental hospital inmatesdeclined steadily as treatment shifted frominpatientcare (in hospitals) tooutpatientcare. This process of moving mental health care away from largeinstitutions, known asdeinstitutionalization, gained further support duringthe 1970s, as mental patients successfully fought in the courts against involuntarytreatment, against hospitals that provided custodial care rather than therapy,and for the right to treatment in the“least restrictive setting”appropriate fortheir care" "Research suggests that managed care can reduce the costs of mental healthtreatment, at least for less severe illnesses, by encouraging shorter ratherthan longer inpatient stays, outpatient rather than inpatient care, conservativerather than aggressive interventions, and use of lower-level clinicians (such associal workers) rather than psychologists or psychiatrists (Mechanic, 1995,1999:160–162). According to David Mechanic, probably the most influentialsociologist in the area of mental health care, it also may be able to improve thequality of care:By reducing inpatient admissions and length of stay, managedcare programs potentially make available considerable resources forsubstitute services and other types of care. Managed care providesincentives to seek closer integration between inpatient and outpatientand primary and specialized services to achieve cost-effectivesubstitutions.Managed care also offers the potential to bring...science-basedmental health care into the mental health system more quicklythan traditional programs.... Many individual practitioners resist prac-tice guidelines and scientific findings, preferring their own clinicalexperience, but managed care can put systems in place to measureperformance and to enforce adherence to established standards(1997:45–46).But managed care also carries risks. The emphasis on cost containmentinherent in managed care has affected who offers mental health services, forhow long, and of what type (Scheid, 2001). MCOs encourage the use of clin-icians who charge less per hour, preferring those with master’s degrees to thosewith doctorates and preferring those with doctorates to those with medicaldegrees. To further restrain costs, MCOs press clinicians to offer only short-term treatment of immediate problems rather than long-term treatment ofunderlying problems. As a result, therapists increasingly prescribe medicationseven if“talk therapies”might be more useful.Managed care also has affected how mental disorders are diagnosed. Oneway managed care controls costs is by deciding in advance, based on data frompast patients, how much and what type of care patients with specific diagnosesshould receive. For this system to work, clinicians must assign a diagnosis to eachpatient. This in turn reinforces the medical model of mental illness and the ideathat every person who seeks mental health services has a specific, diagnosablemental illness.At the same time, to contain costs, MCOs are trying to curtail the breadth ofthe diagnostic system (Horwitz, 2002). Because each successive edition of theDSMhas included more diagnoses, more individuals have become eligible formental health care with each edition. For this reason, MCOs often oppose newdiagnoses or any broadening of the criteria for existing diagnoses. For example,some MCOs deny treatment to individuals who have fewer than five symptomson a depression checklist even if individuals’listed symptoms are severe and eve"