The Medicalization of Deviance
drawn from Goode, 1994-2008
See the disclaimer)
element: whose reality is the right one?
to crazy world=mental health?
as a tool for the healthy?
(which are what); Degrees/shades of gray not like other diseases: Psychosis---Neurosis
- Hard: Biophysical
- Soft: disease metaphor-variety
- Although some helped,
not all. Often treatment is maintenance
disorder is a designation, a definition of a state of mind that produces behavior
that is an adaptation to the social environment-based on a variety of factors:
always objective, but subjective judgment
a disease, but a judgment based on extra-psychiatric factors
(Scheff): Residual Deviance
- Behavior violates
- No specific category
- Leads to label (act
- Many sources/causes
- Most normalized,
- Many violate, few
- Some persist==>
- Learn norms and
stereotypes--childhood, constantly reinforced in EDL (D. Phillips and help
- When labeled; Rewards
and Punishments for conforming to label or not
may not fight label, convenience, relieves anxiety, safety (looking-glass-self)
- Career: Goffman:
Diverse individuals processed through institutional structures end up as
uniform in social status and self-concept.
- Yes, there
is a problem, but labeling and stigma are a part of it.
- Anticipation of
negativity can lead to behavior
- More distant the
relationship--more likely the label: Intimacy- H/W and resistance
- Access to other
and/or Social Reaction
reason for objective definitions, and treatments often work
this doesn't negate the extra-psychiatric factors
and involuntary admission and discharge
- Classic case-uniformity
- Less clear-USA
85%-schizophrenia vs 7% British
agree that measuring mental disorder in the population, or in certain segments
of the population is problematic. There is a huge non-institutionalized segment
of the population who would be diagnosed as mentally disordered were they to
be evaluated by a psychiatrist."
- the study of the distribution of diseases in the population.
- The field of psychiatric
epidemiology is based on the idea that there is, or can be, a "true" rate
or prevalence of mental disorder, just as there is a "true" rate of cancer
- Essentialist assumption
- mental disorder is a concrete entity on whose reality all reasonable and
informed observers can agree.
- mental disorder is a socially determined judgment, the "true" rate
or prevalence of mental illness can not be determined. They are interested
in how mental disorder is conceptualized and defined, how certain categories
in the population come to be designated as having higher, or lower, rates
of mental disorder and what extra psychiatric factors influence rates of
"Another measure of
mental disorder has been developed: a diagnostic interview schedule, which,
presumably, can determine mental condition in a sample of respondents." Relatively consistent results within a society
Women v Men
Males are significantly more likely to be admitted to mental hospitals than females, and the ratio of
males to females is increasing over time.
- Women have somewhat
higher rates of mental disorder than men.
- One nationally
representative study of households across the United States conducted jointly
by the National Institutes of Health and the National Center for Health
Statistics identified 1.94 million females and 1.32 million males as having
serious mental illness; rates of mental disorder were 20.6 for females and
15.5 for males.
- The Epidemiological
Catchment Area Project study, which focused on five urban centers, found
rates of mental disorder of 16.6 for females and 14.0 for males
- A later study using
the same research instrument, based on a more nationally representative
sample in 1994 reached the same conclusion.
Experts believe that this
disparity is due to the conjunction of the specific type of mental disorder
males are more likely to suffer from (an essentialistic phenomenon) and professional
stereotyping (a constructionist phenomenon).
- In 1900, there
were 110 males admitted to state mental hospitals for every 100 females;
by 1975, this had risen to 183, and it remained between 172 and 186 between
the late 1970s and the 1990s. In 1990, there were 146.6 male admissions
per 100,000 males in the population and 80.3 female admissions per 100,000
females in the population.
There is a "double
standard" among clinicians in the diagnosis, hospitalization, and release of
mental patients with respect to gender.
- Men are strikingly
more likely to fall victim to antisocial personality disorders. Antisocial
personality is highly likely to cause havoc in the lives of others- for
instance, in the form of aggressiveness and violence. Thus, someone who
causes disruptive social and interpersonal trouble is more likely to be
- Women are far more
likely to suffer from a mood disorder, especially depression. Depressive
mood disorders are more likely to result in withdrawal and isolation. Thus,
women are less likely to be institutionalized.
- The mental disorder
of men, holding severity of disorder constant, is regarded as more disabling,
threatening, and dangerous to the society than is that of women. Women are
regarded as more cooperative and compliant and more readily influenced by
the hospital staff and, therefore, are more likely to be released.
- Psychiatrists and
clinical psychologists seem to have a lower standard of mental health for
women than for men. They are more likely to diagnose mental disorder for
men. A woman's condition would have to be more severe to warrant hospitalization,
and a man's less severe to warrant release.
- In a sexist or
patriarchal society, males are expected to perform in a society to more
exacting standards. Being a man in a very achievement-oriented society is
incompatible with being mentally disordered; the penalties for stepping
out of line are swift and strong.
- Where women are
relegated to an inferior and dependent role, their performance in that role
is met with more indulgence and leeway. A mildly psychiatrically impaired
woman can perform in an imperfect fashion and still "get by".
- These sexist values
result in a higher rate of mental illness labeling for men, supposedly the
more powerful social category, and less for women, who are generally powerless.
- Single, never
married men are strikingly more likely to score high on every available
measure of mental disorder than are married men; separated and divorced
men rank somewhere in-between.
The special protection
that supposedly extends to men seems to offer no special protection for women.
Women suffer as a result of being married, because marriage is more demanding
- Men who are married
and stay married are more stable, psychologically healthy, and conventional
than men who never marry and therefore, they are less mentally disordered.
The kind of man who marries is also the kind of man who exhibits relatively
few personality problems, while the man who does not marry is far more likely
to exhibit those same problems. Men with severe mental problems are not
considered desirable partners and thus, will be socially avoided by women.
- Being married is
conducive to a man's mental health, security, and well being. "Marriage
does not prevent economic and social problems from invading life, but apparently
can help fend off the psychological assaults that such problems otherwise
- A man who is mentally
ill is seen by all women as an undesirable partner, while a woman who displays
certain mental disorders may still be considered marriageable. The evidence
seems to favor few differences in the impact of marriage between men and
women should strike the observer forcefully.
may be good for men and of considerably less consequence for women. In
a less patriarchal society, marriage will become more equalitarian and possibly,
equally good for both sexes.
- SES is the
most frequently studied: indicators measuring socioeconomic status are income,
occupational prestige, and education.
- Mental disorder
is very closely related to socioeconomic status: the higher the SES, the
lower the rate of mental disorder; the lower the SES, the higher the rate
of mental disorder.
- People at the bottom
of the class ladder are far more likely to suffer from psychiatric distress,
especially schizophrenia, than those at the top.
- There are a few
mental disorders that are more common toward the top of the class structure,
such as obsessive-compulsive neuroses and some mood disorders, but the most
serious illnesses, especially schizophrenia, are most common toward the
bottom of the class structure.
- The kinds
of disorder exhibited by lower-status persons are more likely to come to
the attention of the authorities than the kinds of disorders exhibited by
middle and upper status persons.
- Lower-status persons
are less likely to attribute their problems to a psychiatric condition,
since they are more likely to feel that some stigma adheres to consultation
with a "shrink" or being committed to a mental hospital. Hence, they are
less likely to seek out psychiatric assistance voluntarily.
- Lower-status persons
are most likely to come to the attention of psychiatric authorities as a
result of referral by the police or a social worker.
does not say that lower-SES persons are more mentally disordered than middle
and upper SES persons overall so much as it focuses on how certain conditions,
differentially distributed by social class, intersect with the social structure.
- This strong
inverse relationship between SES and mental disorder may be due to class
bias and the labeling process.
- Middle-class psychiatrists
find lower-class behavior troublesome and are more likely to label it disordered
than the behavior of middle-class persons.
- Mental health is
judged by a middle-class yardstick.
the behavior of the psychiatrically disordered is deemed undesirable by members
of all social classes.
- Economic deprivation,
poverty, occupational instability and unemployment are strongly related
to psychological impairment.
selection or the drift hypothesis
It is likely that
social class contributes more to mental disorder than mental disorder contributes
to social class.
- Social class
is a consequence rather than a cause of mental illness.
- The mentally disordered
are incapable of achieving a higher position on the SES hierarchy because
they are mentally disordered.
- Members of the
lower class who are mentally disordered are either stuck there or have drifted
there because their mental disorder prevents them form achieving a higher
position. Their disorder retards their social mobility.
Being Sane in Insane Places
sanity and insanity exist, how shall we know them?"
Rosenhan decided to answer this question by having eight normal or
"sane" persons including, himself, gain "secret admission" to 12 different
mental hospitals around the country complaining of hearing hallucinatory
voices. All were admitted with a diagnosis of schizophrenia, except one,
which was diagnosed as a manic-depressive. All were released with a diagnosis
of "in remission," without signs of mental illness.
- Rosenhan's conclusion
is that psychiatry "cannot distinguish the sane from the insane." For Rosenhan,
the fact that no one detected the pseudo patients as "sane" and they were
released with a diagnosis of "in remission" was significant; this means that
in the judgment of the hospital, they were neither sane, nor had they been
sane at any time.
Spitzer, a critic of Rosenhan's argues exactly the reverse: the fact that these
patients were discharged "in remission" or free from any signs of mental illness,
indicates that the psychiatric profession is able to detect mental disorder
because the psychiatrists who discharged the pseudo patients "all acted rationally
as to use a discharged category that is rarely used with real schizophrenic
patients". Spitzer admits, "there are serious problems with psychotic diagnosis,
as there are with other medical diagnosis. However, diagnosis is not so poor
that it cannot be an aid in the treatment of the seriously disturbed psychiatric
patient". Thus, a correct interpretation of "On Being Sane in Insane Places"
contradicts the author's conclusions. "In the setting of a psychiatric hospital,
psychiatrists are remarkably able to distinguish the 'sane' from the 'insane'
and the Pharmacological Revolution
TREATMENT OF MENTAL DISORDER
BUT: This decline is
not due to the number of admissions to mental hospitals, which actually increased
from 178,000 in 1955 to 385,000 in 1970, and then declined to about 255,000 in
1992. Also, the length of stay has declined sharply, from six months in 1955 to
15 days in 1992.
- In 1952 in
France, and in the United States in 1954 the first anti-psychotic drug was
introduced. Chlorpromazine, or Thorazine, was the first anti-psychotic that
helped reduce the most blatant, florid, and troublesome symptoms of
institutionalized schizophrenic mental patients.
induced a more "normal" psychological condition in patients; thus it was
possible to release patients into the community as outpatients, with only
minimal treatment and care in aftercare facilities.
- releasing the mentally ill from large hospitals into the community.
- In 1955, there
were nearly 560,000 patients in residence in public mental hospitals; this
figure dropped almost every year until, by the 1990s, it was 80,000.
- Maintenance vs.
- Most not "normalized"
- BUT, costs reduced
and psycho-surgery down
- Regardless of
the precise timing and the causal mechanism of this change, it is impossible
to argue that it could have come about in the absence of administration of
anti-psychotics to schizophrenic mental patients. Today, roughly 85% of all
patients in public mental hospitals are being administered some form of anti-psychotics
- Studies have
shown that roughly three-quarters of all acute schizophrenics demonstrate
significant improvement following the administration of anti-psychotics drugs
and between 75% to 95% of patients relapse if their medication is discontinued
what this has produced is a huge population of mentally ill homeless people
who are subject to virtually no supervision or treatment.
BUT: Anti-psychotics are not cures for mental illness, they
calm the agitated disturbed patient; the symptoms of mental illness are no
longer as troublesome to others as they once were: they do not manifest their
former signs of craziness. They do have side effects.
deviant (trouble and unpredictable)==> more likely to be medicalized
medically, not because they're bad; but because they're sick
more public debate, disease is the domain of experts
cure may be worse than punishment
distorts the cultural and value basis of the definitional process
Disorder and Deviance
and Pity vs. outrage and loathing
free will-at least with medical model
disorder is highly generalizable, classic Master Status
as deviance: The Sick Role
culturally defined and accepted medical help
health care providers orders
to move out of the sick role, i.e. do not stay sick longer than necessary
lack of desire to be sick
role as temporary and involuntary
Physical Characteristics as Deviance