Sociological Approaches to Mental Illness PDF

6 Sociological Approaches to Mental Illness Peggy A. Thoits The sociological approach focuses on the factors external to the individual – the environmental or...

6 Sociological Approaches to Mental Illness Peggy A. Thoits The sociological approach focuses on the factors external to the individual – the environmental or social context – and views mental illness as a breakdown in the face of overwhelming environmental stress. Thoits provides an overview of three dominant theories, or models, and describes their basic assumptions, advantages and limitations, and implications for treating or preventing mental illness. Stress theory is based on evidence that accumulations of social stressors can precipitate mental health problems. The relationship between stress expo- sure and psychiatric symptoms, however, is not strong because individuals have extensive coping resources to help them handle stress. Researchers focus on the relationship between stress and coping mechanisms and also on the unequal distribution of stressful experiences and a variety of coping resources in the population. One reason why higher rates of mental disorder and psychological distress are found in lower status, disadvantaged groups is that these groups are more likely to be exposed to stressors and less likely to have important coping resources. To treat mental illness, one needs to eliminate or reduce stressors, teach individuals different coping strategies, and bolster their personal resources. Structural strain theory locates the origins of disorder and distress in the broader organization of society. Mental illness may be an adaptive response to structural strain or to one’s degree of integration into society. For example, during periods of high unemployment, admissions to treatment for psychosis increase, whereas periods of economic upturns are associated with lower rates of hospitalization. A structural condition, hard economic times, causes people to experience major stressors and provokes mental illness. Society’s organization places some groups at a social or economic disadvantage. To prevent or reduce mental illness, society must be restructured in a fairly major way, for example, by creating a guaranteed minimum income to eliminate the strains of unemployment. A third approach to mental illness is labeling or social reaction theory. The logic behind labeling the- ory is that people who are labeled as mentally ill, and who are treated as mentally ill, become mentally ill. Symptoms of mental illness are viewed as violations of the normative order whereby individuals violate taken-for-granted rules about how one should think, feel, and behave. The way to reduce or prevent mental illness is to change those norms that distinguish what is normal behavior from that considered abnormal. Although this approach may seem idealistic, labeling theory has been very important in alerting us to the consequences of labeling and institutionalization. Students should think about the various ways the three sociological approaches to mental illness complement each other and contribute to the biological and psychological understandings of mental disorder. 106 https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 107 Introduction The three general approaches to mental illness that are discussed in this volume can be broadly characterized by their underlying metaphors. The biological or medical approach views mental illness as if it were a disease or physical defect in the brain or body. The psychological approach treats it as if it were a sickness or abnormality in the mind or psyche (i.e., the soul). And the sociological approach views mental illness as if it were a breakdown in the face of overwhelming envi- ronmental demands. The key distinction between the biological and psychological perspectives on the one hand and the sociological perspective on the other is the location of the primary cause of mental illness. From the biological and psycho- logical approaches, the determinants of mental illness are internal – “in” the person (in the physical body or in the person’s mind). From a sociological approach, the cause is external – in the environment or in the person’s social situation. Although obviously oversimplifying the differences among the three approaches, this char- acterization helps clarify the focus of this chapter – on the social, rather than biological and psychological, origins of mental illness. Within the social approach, there are three dominant theories of mental illness etiology (where etiology means the study of the origins or causes of a disease): (1) stress theory, (2) structural strain theory, and (3) labeling theory. This chapter describes each theory’s basic concepts and assumptions, theoretical limitations and advantages, and implications for treating or preventing mental illness. Stress Theory Hans Selye, a medical researcher, introduced the term stress into scientific dis- course in the mid-1930s. By stress or stressors he meant anything that puts wear and tear on the body, usually noxious environmental stimuli. Because he experi- mented with laboratory animals, stressors meant such conditions as extreme heat or cold, overcrowded cages, and repeated electric shocks. Selye (1956) argued and showed that prolonged or repeated exposure to noxious stressors eventually depleted the body’s physical defenses and that laboratory animals almost inevitably succumbed to disease or infection when that happened. Because laboratory studies convincingly established a relationship between prolonged or repeated stress exposure and disease in animals, speculation turned to the effects of stress on human beings. Researchers began to focus on social stressors, in particular, on major life events (Holmes & Rahe, 1967). Thomas Holmes and Richard Rahe defined life events as major changes in people’s lives that require extensive behavioral readjustments. They hypothesized that having to readjust one’s behavior repeatedly or substantially could overtax a person’s ability to cope or adapt, thus leaving him or her more vulnerable to physical illness, injury, or even death. To test this hypothesis, Holmes and Rahe first went through the https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  108 Peggy A. Thoits medical records of Navy personnel, recording the most common life events that preceded Navy men’s doctor visits and hospitalizations and abstracting a list of 43 major life events. Next they asked groups of people to judge (independently of one another) how much behavioral readjustment each event on their list required. Table 6.1 shows the resulting Social Readjustment Rating Scale, with the 43 events ordered by their average “life change unit” scores, that is, by the amounts of behavioral readjustment (from 0 to 100 units) that people believed they require. This life events checklist gave social researchers an easy way to assess whether exposure to social stressors would have health consequences for human beings. The answer was clear: The more life events that individuals experienced in a given period of time (say, during 6 months or a year) and the higher their readjustment scores, the more likely they would have an injury, an illness, or even die (Cooper, 2005; Cohen, Janicki-Deverts, & Miller, 2007; Tennant, 1999). Literally hundreds of studies showed a significant relationship between the amount of life change that one experienced and illness, including heart attacks, strokes, tuberculosis, ulcers, asthma attacks, flu, and even the common cold (S. Cohen, 1996). More exciting to mental health researchers, studies found that major life changes were significantly associated with the onset of anxiety, depression, schizophrenia, and generalized states of psychological distress (Thoits, 1983, 1995). An accumulation of social stressors, then, could precipitate mental health problems.1 Soon after the discovery of these basic relationships, investigators’ attention turned to the types of stressors that were most likely to precede the onset of mental illness.2 Notice that Holmes and Rahe’s Social Readjustment Rating Scale implicitly assumes that all life events, both positive and negative, can require behavioral readjustment and thus overtax individuals’ coping resources and leave them physically or emotionally vulnerable. However, researchers next found that 1 You may have noticed that there are several problems with Homes and Rahe’s SSRS. For example, many important life events are missing from the list (e.g., losing custody of one’s children, “coming out of the closet,” a parent remarries); in fact subsequent life events checklists have been expanded to include anywhere from 100 to 200 events (Dohrenwend et al., 1978). Another problem is that the events on the SRRS tend to be ones that happen primarily to males and Whites; events that are experienced more by women or minority group members are underpresented. Also, many items on the SRRS are possible symptoms of psychological problems rather than events in themselves, for example, changes in eating habits, changes in sleeping habits, sexual difficulties). Researchers have since gone to extensive lengths to eliminate these and other problems (Wethington, Brown, & Kessler, 1995). However, even with improved life events measurement, the same basic relationships reported in your text are still found. 2 It is important to understand that laypersons often use the term stress ambiguously and that this ambiguity must be avoided for clarity. Stress can refer to the cause of the psychological problems (e.g., negative events), or it can describe one’s subjective emotional experience (e.g., “I feel so stressed). To avoid this ambiguity, researchers usually restrict the term stress or stressor to refer to major life events and chronic strains – the environmental causes of emotional problems. The phrases “stress reaction” or “stress response” are used to distinguish emotional consequences from their environmental causes. In this book, psychological distress and mental disorder are the stress reactions of primary concern, and major life events and chronic strains are the causal factors. https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 109 Table 6.1. Social readjustment rating scale Rank Event Life change units 1 Death of spouse 100 2 Divorce 73 3 Marital separation 65 4 Jail term 63 5 Death of close family member 63 6 Personal injury or illness 53 7 Marriage 50 8 Fired at work 47 9 Marital reconciliation 45 10 Retirement 45 11 Change in health of family member 44 12 Pregnancy 39 13 Sex difficulties 39 14 Gain of new family member 39 15 Business readjustment 39 16 Change in financial state 38 17 Death of close friend 37 18 Change to different line of work 36 19 Change of number of arguments with spouse 35 20 Mortgage or loan over $10,000 31 21 Foreclosure of mortgage or loan 30 22 Change in responsibilities at work 29 23 Son or daughter leaving home 29 24 Trouble with in-laws 29 25 Outstanding personal achievement 28 26 Wife begins or stops work 26 27 Begin or end school 26 28 Change in living conditions 25 29 Revision of personal habits 24 30 Trouble with boss 23 31 Change in work hours or conditions 20 32 Change in residence 20 33 Change in schools 20 34 Change in recreation 19 35 Change in church 19 36 Change in social activities 18 37 Mortgage or loan less than $10,000 17 38 Change in sleeping habits 16 39 Change in number of family get-togethers 15 40 Change in eating habits 15 41 Vacation 13 42 Christmas 12 43 Minor violations of the law 11 Source: Thomas A. Holmes and Richard H. Rahe (1967), “The Social Readjustment Rating Scale,” Journal of Psychosomatic Research, 11, 213–218. https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  110 Peggy A. Thoits when events were subdivided into culturally desirable (positive) and culturally undesirable (negative) types, undesirable events were more strongly associated with psychological problems than desirable events were (Ross & Mirowsky, 1979; Brown & Harris, 1978). George Brown and Tirril Harris’s path-breaking socio- logical study of life events and depression offered compelling evidence for this relationship. Brown and Harris randomly selected about 460 women in the city of Camber- well, outside London, for in-depth interviews. Through the interviews they estab- lished whether any of the women met the clinical criteria for major depression and, if so, the month when the depression had begun. About 15% of the women in the Camberwell community sample were found to be clinically depressed at the time of the study. A central part of the interview canvassed all of the major life changes and chronic difficulties the women had experienced over the past year or up to the point of depression onset. Importantly, this was not a simple checklist type of assessment, but instead an in-depth, probing discussion of the various changes and difficulties the women had been through in the past year. Brown and Harris defined “severe” life events as negative events that most people would agree are serious long-term threats to personal well-being. They found that severe events predicted the onset of major depression much better than “non-severe” events, which referred to minor negative events and positive events. These researchers discovered, too, that ongoing difficulties (sometimes called chronic strains) were almost as important as severe negative events in predicting depression. Examples of ongoing difficulties are living in overcrowded conditions, having persistent family arguments, and having too little money to buy necessary food, clothes, or medicine. When severe events and long-term major difficulties were considered together, Brown and Harris found that 89% of the depressed women had experienced one or both types of stressors in the past 9 months whereas only 30% of the nondepressed women had experienced those conditions during the same time period. So Brown and Harris concluded that acute negative events and chronic strains put individuals at much higher risk of developing major depression. Note that it is not all changes, positive and negative, but only negative changes in people’s lives that are causes of psychological problems. Subsequent research showed that negative events and chronic strains also pre- dicted the onset of schizophrenia, anxiety attacks, and milder states of depression and generalized distress (Thoits, 1983, 1995; Turner, 1995; Turner & Lloyd, 1999). In other words, acute events and chronic strains (the latter defined as environmen- tal demands that require repeated or daily readjustments in behavior over long periods of time) are causally implicated in a variety of forms of mental illness, from mild to severe.3 Research has also pinpointed the types of events that more 3 Researchers have also studied “hassles” as types of stressors that may cause psychological problems (Kanner et al., 1981). Hassles are mini-events, small changes requiring immediate readjustment in one’s behavior. Examples include getting stuck in traffic, having unexpected company arrive, and losing one’s wallet. Although there is evidence supporting a relationship between mounting hassles https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 111 often precede psychological disorder, such as events that are unexpected, uncon- trollable, and clustered in time; traumatic experiences; and unresolved problems. You will learn more about these various types of stressors and their effects in Part II of this volume. As findings on the psychological effects of stress mounted, researchers began to turn their attention to a related problem: Although there clearly is a relationship between exposure to stressors and the subsequent development of psychological problems, this relationship is not strong. The strength of a relationship is measured as a correlation. A correlation between two variables ranges in value from.00 (no relationship at all) to 1.0 (a perfect positive relationship – that is, for each nega- tive event experienced, there is an accompanying unit increase in psychological symptoms). Most studies report correlations around.30, which is a very modest correlation between stressors and symptoms of psychological distress or disor- der. In other words, many people who experience severe stressors do not become disturbed, whereas others who experience few or minor stressors do. Why is this? According to elaborations of stress theory (Lazarus & Folkman, 1984; Pearlin, 1989; Pearlin, Lieberman, Menaghan, & Mullan, 1981), the modest correlation between stress exposure and symptoms occurs because many individuals have extensive coping resources and use effective coping strategies when handling stressful demands, thus buffering the negative psychological impacts of those demands. Coping resources refer to social and personal reserves from which people draw when dealing with stressors (Pearlin & Schooler, 1978). Social support is a key social coping resource; it consists of emotional, informational, or practical assistance with stressors from significant others such as family or friends. Two important personal coping resources are self-esteem and a sense of control or mastery over life. People who have high self-esteem and those who strongly believe that they are in control of their lives are more likely to engage in active problem- solving efforts to overcome problems (Folkman, 1984; Pearlin et al., 1981; Taylor, 2007; Taylor & Aspinwall, 1996) or to use a variety of coping strategies flexibly to meet stressful demands (Folkman & Moskowitz, 2004; Mattlin, Wethington, & Kessler, 1990; Pearlin & Schooler, 1978). Coping strategies are usually defined as behavioral or cognitive attempts to manage situational demands that one perceives as taxing or exceeding one’s abil- ity to adapt (Lazarus & Folkman, 1984). They are typically subdivided into two types: problem-focused and emotion-focused coping strategies. Problem-focused coping efforts are directed at changing or eliminating the stressful demands them- selves. Emotion-focused strategies are attempts to alter one’s emotional reac- tions to stressful demands, for example, through distraction, avoidance, or ten- sion release. Pearlin and Schooler (1978) distinguished what might be called and emotional upset, hassles scales are problematic because they mix in major events, chronic strains, and possible psychological symptoms with true mini-events (Dohrenwend et al., 1984). Hence, the findings of hassles scales are not emphasized here. https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  112 Peggy A. Thoits meaning-focused coping, or cognitive coping, from other emotion-focused strate- gies. Meaning-focused coping consists of mental efforts to alter one’s perceptions of stressful demands so that they seem less threatening or overwhelming (e.g., reinterpreting the situation, looking on the bright side of things). Lazarus and Folkman (1984) classified such cognitive strategies as emotion focused in nature because they can reduce emotional reactions to demands, but do not change the demands themselves. Research shows that, in most stressful episodes, people use both problem- focused and emotion-focused strategies, including meaning-focused ones (Folkman & Lazarus, 1980; Taylor & Aspinwall, 1996). For example, when facing a major exam, students may attack the problem by studying an hour or two each day and practicing answers to possible test questions. They may control their anxiety by telling themselves that they understand more of the material than other students do, reminding themselves that they have done well before on these kinds of tests, and perhaps, engaging in some strenuous exercise to ease physical tension. Despite the fact that most people use a variety of coping strategies when facing stressors, difficulties that can be changed or controlled tend to elicit more problem-focused efforts, whereas intractable problems tend to generate more strategies that are emotion focused (Taylor & Aspinwall, 1996). Escapist or avoidant strategies are consistently associated with poor mental health (Folkman & Moskowitz, 2004). As Chapter 10 shows in more detail, coping resources (e.g., social support, self- esteem, sense of control) and certain types of coping strategies buffer or reduce the negative psychological impacts of stressors. This is why the relationship between stress exposure and psychological problems is far from perfect – in essence, people are able to protect themselves from being overwhelmed by stressful demands. However, some people are poorly equipped to protect themselves because they lack social support or a sense of control over their lives or have not acquired efficacious coping strategies. Of crucial importance to sociologists of mental health is the finding that life events and chronic strains, as well as social support, self-esteem, and a sense of mastery, are unequally distributed in the population, leaving some groups of people (e.g., women, the elderly, the very young, the unmarried, those of low socioeconomic status) both more likely to experience certain stressors and more vulnerable to the effects of stressors in general (Turner, 1995; Turner & Marino, 1994; Turner & Roszell, 1994). These key findings point very clearly to the important role that social factors can play in the etiology of mental illness and psychological distress. Moreover, they suggest an explanation for the higher rates of mental disorder and psychological distress found in lower status, disadvantaged groups (see Chapter 12) – these are the groups that are more likely to be exposed to stressors and less likely to have important coping resources. The advantages of stress theory are several. First, the theory focuses on aspects of the individual’s current social situation that the biological and psychological approaches tend to deemphasize or ignore as etiologically important. Second, it https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 113 helps explain why psychological distress and disorder occur more frequently in lower status groups than in higher status groups, patterns that the biological and psychological perspectives have difficulty explaining parsimoniously. Third, stress theory allows for more direct empirical testing than the biological and psycholog- ical approaches do. Conventional survey and interview methods allow researchers to measure key concepts (e.g., stressors, coping resources, social support) and to test relationships among them explicitly, unlike biological studies in which researchers must infer from the effects of specific drugs an association between, for example, serotonin uptake and major depression. Similarly, psychological researchers must assume a relationship between childhood traumatic experiences and mental illness from the effects of psychotherapy, which often unearths such past experiences. Finally, as you will see in later chapters, considerable empirical evidence supports the stress explanation of psychological disturbance. Despite these advantages, however, the limitations of the theory should not be ignored. One key limitation is that stress theory cannot explain why this person and not that one became mentally ill; in other words, it cannot explain individual cases of psychological disorder. Stress theory is better suited to explaining group differences in psychological problems – for example, why lower class persons are more likely to have a mental disorder in their lifetimes than are middle and upper class people or why individuals without social support are more vulnerable to stressors than people who have it. Second, stress theory is nonspecific with respect to outcomes; it does not explain why some groups are more prone to certain disorders, whereas other groups develop different disorders (for example, why women become depressed and anxious and why men develop antisocial personality disorder and more often abuse drugs and alcohol). Finally, the theory does not apply equally well to all types of mental disorders. Stress theory is most relevant to affective and anxiety disorders (i.e., mood-related disorders) and to adjustment disorders; people clearly become depressed or anxious in response to stressors or have trouble adjusting to them. It is more difficult to explain the etiology of psychoses with stress theory; psychoses by their very seriousness and complexity seem to require additional explanatory factors, such as genetic predisposition, imbalances of certain chemicals in the brain, and faulty childhood socialization. In short, to explain psychoses, and perhaps to explain most clinical disorders adequately, one might better employ diathesis-stress theory (Rosenthal, 1970), which posits that disorder is the result of a diathesis (technically, a constitutional or genetic weakness, but more generally used to mean “vulnerability”) combined with exposure to stress. Diathesis-stress theory suggests that the experience of stress alone is not sufficient to cause mental disorder; instead, stressors may cause disorder when they occur along with other vulnerability factors in a person’s body, psyche, or circumstances. The treatment implications of stress theory are straightforward and quite dif- ferent from biological and psychological approaches. To treat or prevent mental https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  114 Peggy A. Thoits illness one needs to change the person’s situation (i.e., eliminate or reduce stres- sors), teach the person different coping responses (i.e., encourage better man- agement of stressors), or bolster his or her personal and social resources (i.e., increase available social support, raise self-esteem, or empower a stronger sense of control). Because directly changing people’s life situations can be intrusive or expensive, interventions aimed at people’s actual sources of stress are less frequently attempted than efforts aimed at enhancing their coping strategies or their personal and social resources. Some well-crafted experiments (see Caplan, Vinokur, & Price, 1997, for examples) have shown quite clearly that interventions to change people’s coping strategies and to bolster their social support do, in fact, reduce their emotional reactions in response to major life events (e.g., a diagnosis of cancer, major surgery, divorce, unemployment). Thus, stress theory offers real promise for devising preventive mental health interventions. Structural Strain Theory Structural strain theory is an umbrella term that covers several more specific sociological hypotheses about mental illness etiology. In contrast to stress theory, which focuses on specific events and strains in people’s social lives as causal, structural strain theory locates the origins of distress and disorder in the broader organization of society, in which some social groups are disadvantaged compared to others. Merton’s (1938/1968) anomie theory of deviance provides a useful example of a structural strain theory. Merton’s anomie theory attempts to explain the occurrence of deviant behavior in general (including criminal, addictive, and rebellious behaviors), not just mental illness. Merton argued that American culture emphasizes success and wealth as important values; Americans are taught to desire and strive for economic success above almost all other goals. American society also views educational attainment as one key means, if not the key means, to economic success. Merton assumed that most people view the educational system as a legitimate route to the widely shared goal of financial success. Unfortunately, large segments of society also perceive (correctly) that their avenues to success are systematically blocked. The poor and minority group members live in neighborhoods with inadequate school facilities and poorly trained teachers; they lack the preparation, encouragement, and financial assistance to pursue higher education; and they experience class-based and race-based discrimination in schools and in the labor force, which defeats efforts to succeed while following legitimate paths. Merton used the term anomie to describe the gap between cultural goals (e.g., desires for financial success) and the structural means to those goals (e.g., access to adequate education and employment). He argued that people who experience anomie adapt to that dilemma in one of several possible ways: by changing their https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 115 Table 6.2. Merton’s anomie theory of deviance: Responses to anomie Adherence to cultural Seek legitimate goal of economic success means to success Conformity + + Ritualism − + Innovation + − Retreatism − − Rebellion +/− +/− Notes: +, acceptance; −, rejection; +/−, rejection and substitution of new goals and means. goals, pursuing alternative means, or both. Merton described five adaptive responses, which are displayed in Table 6.2. “Conformists” are people who continue to adhere to culturally shared goals and to pursue conventional means to those goals, despite the awareness that these efforts are unlikely to pay off. “Ritualists” are those who reduce their aspirations (give up the possibility of ever achieving success), yet continue to behave in socially acceptable ways (they perhaps finish high school and work steadily at some low-pay, low-prestige job). Neither conformist nor ritualist responses create major social problems. However, the remaining three adaptive responses are generally viewed as behaviorally deviant and hence socially problematic. “Innovators” are people who continue to desire and seek wealth, but resort to illegitimate means to reach that goal, rejecting legitimate means; innovators are essentially society’s criminals, from simple thieves to executives engaged in fraud and tax evasion. “Retreatists” are those who give up the goal of success and who stop attempting to follow legitimate avenues. Instead, they retreat from the world into substance abuse or mental disorder. Finally, “rebels” are people who reject both the goals and the socially acceptable means to those goals and substitute both new goals and new avenues; these are people who lead or participate in social movements or, more threateningly, riots and rebellions. Although it is clear that Merton could have generated additional adaptive responses (a person could substitute new goals while following legitimate avenues, for example), the central point to be extracted from his analysis is this: Mental illness is an adaptive response to structural strain. Specifically, it is a response to finding one’s legitimate roads to valued rewards irrevocably blocked. Importantly, that blockage is not due to one’s own inadequacies but to the structure (hierarchical organization) of society, which unfairly privileges the desires and efforts of some social groups over others. Like Merton’s more general theory of deviance, most structural strain explana- tions of mental illness suggest that strains in macro (i.e., large-scale) social and https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  116 Peggy A. Thoits economic systems cause higher rates of mental disorder or mental hospitalization for certain groups. Before Merton, Emile Durkheim, a French sociologist, ana- lyzed the social causes of suicide, a behavior that on the surface seems highly psychological and individual in nature (1897/1951). Durkheim found unequal dis- tributions of suicide within and across societies. For example, Protestants had higher rates of suicide than either Catholics or Jews; unmarried people, especially those without children, had higher rates than married people or parents; military men committed suicide at higher rates than civilians; and suicide rates were higher during times of rapid economic expansion and depression than during more sta- ble economic periods, among many other patterns. Searching for an underlying explanatory factor, Durkheim eventually argued that groups and societies differ in their social integration, which he defined as the degree to which people are bound together and regulated by shared norms. He maintained that norms (i.e., rules that guide appropriate behavior in specific situations) serve to moderate our passions and sustain our ties to others, preventing our desires and emotional impulses from spiraling out of control. Members of groups that are weakly integrated, then, suffer from disappointment and misery because their escalating passions, unregulated by norms or relations with others, inevitably go unfulfilled. Durkheim called this kind of suicide “egoistic suicide,” because individuals in poorly integrated groups are more likely to succumb to despair caused by unchecked and unfulfilled per- sonal desires. On the other hand, Durkheim recognized that social integration can be too strong, leading some to commit what he called “altruistic suicide.” In overly integrated groups, individuals subordinate their passions and impulses for the good of the group, adhering to strong rules that guide almost all aspects of daily experience (military life is a good example). When the group or society is threatened, its members are therefore more likely to sacrifice themselves for the community. Finally, Durkheim described “anomic suicide,” a condition induced by rapid changes in social structure and breakdowns in norms. Durkheim’s concept of anomie refers to a state of normlessness or normative confusion (notice that Merton’s term “anomie” means something different, although related). Societies or groups undergoing rapid social or economic change (e.g., sudden increases in the divorce rate, sudden changes in the unemployment rate) frequently find that traditional rules for behavior no longer apply. The resulting sense of confusion or normlessness causes individuals’ passions once again to become unregulated, often plunging them into disappointment and despair. In short, according to Durkheim, the cause of suicide resides in the degree to which a society’s members are tied tightly or loosely together through shared normative expectations for behavior. A too weakly or too strongly integrated society and a society undergoing rapid change are conditions of structural (in this case, system-level) strain, manifested in noticeably higher rates of suicide in its members, relative to groups with moderate degrees of integration. https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 117 Evidence for Durkheim’s structural theory of suicide has accumulated over the years. In a classic study, Faris and Dunham (1939) plotted the previous residences of all patients admitted to hospitals for schizophrenia and other psychoses in Chicago during the mid-1930s. They found clear patterns: Schizophrenic patients had lived in poor areas of the city, concentrated in the inner urban core, with high population turnover, a high percentage of rental apartments and boarding houses, and a high percentage of foreign-born (probably immigrant) residents. Thus, they lived in neighborhoods in which few people knew one other or formed lasting ties. Faris and Dunham concluded that schizophrenia was caused, in part, by social disorganization and the prolonged or excessive social isolation that it produced.4 A dramatic example of the consequences of social disorganization can be found in Kai Erikson’s study (1976a, 1976b) of the survivors of the 1972 Buffalo Creek flood in the Appalachian hills of West Virginia. Early on a Saturday morning after heavy rainfall, a dam constructed poorly by the Buffalo Mining Company crumbled and released tons of floodwater, which washed out 13 small coal mining communities in the valley below. Most people, still asleep, were caught by surprise. Many were injured, 125 people were killed, and literally everything in the floodwater’s path was destroyed or swept away. Federal authorities trucked in hundreds of trailers to house surviving residents, freezing people in the scattered locations of their displacement for the next few years (the parallels to the aftermath of Hurricane Katrina in New Orleans in 2005 should be obvious). Through in-depth interviews with survivors, Erikson and other researchers found that the shocks of destruction and damage caused by the flood were compounded by the sudden and permanent loss of community. Connections with kin and long-term neighbors and friends were cut by the survivors’ placements in haphazard emergency housing. Almost all of the survivors suffered from at least some symptoms of posttraumatic stress disorder, which took years to dissipate ( Green, Grace, Vary, & Kramer, 1994; Green, Lindy, Grace, & Gleser, 1990). The Buffalo Creek flood is an example of Durkheim’s concept of anomie – a sudden, massive structural change that produced a sense of normlessness in survivors, causing psychological harm over and above the stressful events of bereavement, injury, and property loss. Erikson’s study reminds us that structural strains need not be at the macro or system level to have consequences; they can be more proximate or local. In recent years, there has been a surge of interest in the impacts of local social structures, 4 It should be noted that Dunham later repudiated the original study’s conclusions. Dunham argued that schizophrenic patients’ residences were likely a result of their mental disorder, rather than a cause of it (Dunham, 1965). In other words, he contended that disorganized neighborhoods do not produce mental health problems in residents; instead, disturbed persons selectively migrate into such neighborhoods because their poor mental health prevents them from having the jobs or money needed to live elsewhere. Although this is a plausible argument, the bulk of the evidence favors the causal influence of disorganized neighborhoods on mental health. https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  118 Peggy A. Thoits especially the effects of poor neighborhoods on residents’ mental health. Poor neighborhoods are characterized by high rates of racial segregation, unemploy- ment, single-headed families, residential instability, crime, and physical decay, among an array of other disadvantages. These features of neighborhood organiza- tion have distressing and depressing influences in themselves while also generating concrete difficulties in residents’ lives and exacerbating the negative psychological consequences of their sparse social support, weak sense of control, and alienation (Aneshensel, 1996; Silver, Mulvey, & Swanson, 2002; Stockdale et al., 2007). Neighborhoods, in short, are contexts or structures that generate chronic strain as well as magnify community members’ personal difficulties. The theme of harmful consequences of social isolation or the lack of social integration recurs in these examples of structural strain. Up to this point, measures of social isolation have been at the group or aggregate, level (e.g., high rates of residential turnover, disruption in a community’s organization). But social isola- tion can also be conceptualized and measured at the individual level, in terms of holding few social roles. Roles are sets of reciprocal rights and obligations attached to specific positions in the social structure, such as husband–wife, parent–child, teacher–student, and physician–patient. These rights and obligations tell incum- bents how to act in relationships with other people and why they should do so. Thus, roles provide behavioral guidance and supply individuals with purpose and meaning in life (Thoits, 2003). Given this, people who have few or no social roles are at greater risk of engaging in deviant behavior (e.g., drug or alcohol abuse, aggressive or impulsive acts) and experiencing anxiety or despair. Considerable research to date confirms that holding multiple roles promotes psychological well-being; conversely, a lack of roles or social isolation is psychologically dam- aging (Thoits, 2003). Hence, even at the individual level, social isolation has mental health implications, consistent with Durkheim’s original thesis developed long ago. Note that stress theory implicitly underlies these examples of structural strain approaches. Structural theorists usually do not spell out the stress implications explicitly because their thinking and empirical research usually stay at the aggre- gate or group level (i.e., their studies examine percentages of female-headed families or rates of unemployment, for example, rather than examining individual people as cases). But it is fairly easy to see the implications of, say, high unem- ployment rates in a community for individuals who are living there. They may be increasingly anxious about losing their jobs; if they are laid off, they may have more trouble finding new jobs with steady pay; and persistent financial difficulties in turn may lead to marital conflict or lack of access to needed medical care, all of which are stressors that may overwhelm individuals’ abilities to cope. That stress theory is necessary to make the link between structural strains and mental health sensible is one of the weaknesses of structural approaches. Struc- tural theorists generally do not elaborate the ways in which broad social structures https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 119 and broad socioeconomic trends become actualized in the lives of specific indi- viduals, and thus they do not clarify how or why macro social trends can produce psychological distress or disorder. Structural approaches, especially studies that focus on neighborhoods, also tend to emphasize class-related or socioeconomic disadvantages as etiologically crucial while neglecting the effects of other large- scale societal changes on mental health. For example, changing trends in the organization and quality of family relationships (e.g., high rates of divorce, more absentee fathers, and increasing numbers of parents or grandparents who are frail and elderly) may be particularly important structural sources of stress in people’s lives. On the other hand, structural strain theories have advantages. The most impor- tant is the unique contribution they make to theories of mental illness etiology. As mentioned earlier, mental illness is not randomly distributed in society; it is concentrated in several demographic groups that are socially and economically disadvantaged or low in power and influence. The theory suggests that the very structure or organization of society itself may play a role in the epidemiology and etiology of mental illness, which is an idea that stress theory, for example, does not capture well and psychological and biological theories miss altogether. (Stress theorists certainly recognize but usually do not capitalize on the idea that stressors may themselves be a product of the very way our society is organized.) If our goal is to understand thoroughly the complex and multiple causes of mental illness, then the strains induced by social systems, social institutions, and community contexts surely must be taken into account. Structural strain theory suggests that to prevent or reduce mental illness in society one must intervene in fairly large-scale ways, for example, by combating racial segregation, bolstering access to college education, buffering spikes in the unemployment rate, and expanding services for the elderly. Such system-level solutions to prevent mental illness require massive (and thus usually expensive) social programs that are difficult for legislators to pass and fund; therefore, the preventive implications of structural strain theory usually go untested and untried (although there have been social experiments that provide guaranteed incomes to poor and working-class families; see Robins, Spiegelman, Weiner, & Bell, 1980, for an example). However, given recent evidence of the importance of local neighborhood contexts for the mental health of their residents, more delimited community-focused interventions might be economically and politically feasible, which target problematic aspects of neighborhood life to better promote members’ social integration and well-being. Labeling Theory Like structural strain theory, labeling theory (sometimes called societal reaction theory) offers a uniquely sociological explanation of the causes of mental illness; https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  120 Peggy A. Thoits some have described it as a radical sociological explanation. The theory has had enormous intellectual impact and has played an important role in the movement to deinstitutionalize the mentally ill. Labeling theory is based on one key idea: People who are labeled as deviant and treated as deviant become deviant. Deviance refers to violation of norms or rule-breaking. In the case of mental illness, symptoms of psychiatric disorder are themselves viewed as normative violations. Symptoms essentially break taken- for-granted rules (Scheff, 1984) about how people should think, feel, and behave (for example, it is not appropriate to believe that the Central Intelligence Agency is tapping your phones; you should not constantly feel anxious or depressed; you should not run naked and screaming through the streets). Labeling theorists (Becker, 1973; Lemert, 1951; Scheff, 1984) assume that everyone violates norms at some time in his or her life for any of a multitude of reasons. Reasons for rule-breaking can include biological causes (e.g., fatigue, undernourishment, genetic abnormalities, illness), psychological causes (e.g., unhappy childhood, a need for attention, internal conflicts, low self-esteem), soci- ological causes (e.g., role conflict, peer pressure, exposure to stressors), cultural causes (e.g., following subcultural norms that differ from those of the dominant society), economic causes (e.g., a need for money, buying prestige in the eyes of others), and even miscellaneous reasons (e.g., carelessness, accidents, sheer ignorance of the rules). Labeling theorists regard these various causes of primary deviance (initial rule-breaking acts, in this case, psychological symptoms) as rela- tively unimportant. What matters is how the social group reacts to an individual’s primary deviance. This is why the theory is often called “societal reaction theory.” Most often, rule-breaking acts are ignored, denied, or rationalized away by family, friends, and the rule-breakers themselves, and (according to the theory) those primary acts are then rarely repeated. However, when individuals’ norm violations are frequent, severe, or highly visible, or when rule-breakers are low in power and status relative to “agents of social control” (i.e., police, social workers, judges, psychiatrists), rule-breakers are much more likely to be publicly and formally labeled as deviant (in this case, mentally ill) and forced into treatment. Why is public, official labeling so important? That is because, once labeled and in psychiatric care, rule-breakers begin to experience differential treatment on the basis of their label (Rosenhan, 1973). People labeled as mentally ill or disturbed are stereotypically viewed as unpredictable, dangerous to themselves or others, unable to engage in self-care, and likely to behave in bizarre ways (Scheff, 1984). These still-common stereotypes cause others, even mental hospital staff, to treat patients as though they were irresponsible children (Goffman, 1961; Rosen- han, 1973). Mental patients hear jokes about crazy people, are reminded of their past failures or inadequacies, and are prevented from resuming conventional adult activities (e.g., leaving the hospital grounds without permission, using the showers or a razor without staff present, making private phone calls, driving a car, returning https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 121 to work, voting, or seeing family or friends at will). One consequence of differen- tial treatment, then, is blocked access to normal activities. Differential treatment also leads to association with similar deviants. In hospitals or treatment centers, patients spend more time in the company of other mental patients than with non- patients. This increased contact in turn allows socialization into the subculture of mental patients; one learns a deviant world view, or a deviant set of values, which reinforces adopting a simple life within the safe, protective walls of the hospital or outpatient day program (Braginsky, Braginsky, & Ring, 1969; Estroff, 1981; Goffman, 1961). The unfortunate outcome of differential treatment, according to labeling theory, is identification with the mental patient role: one takes on the identity of a mentally ill person. And because this identity becomes “who I am,” mental patients continue to expect psychiatric symptoms from themselves and to exhibit symptoms. In labeling theory terms, the patient displays secondary deviance or continued rule- breaking (i.e., continued abnormal behavior or symptoms) because he or she has internalized and identified with the patient role. This process is an example of a “self-fulfilling prophecy” (Merton, 1938/1968). In short, people who are labeled as deviant and treated as deviant become deviant. Mental illness becomes the issue around which one’s identity and life become organized – it becomes a “deviant career.” Why the theory has sometimes been described as radically sociological may now be clear: it turns our usual causal thinking about mental illness on its head. Deviance or mental illness is not “in” the person’s biology or psyche, nor even is it primarily caused by the individual’s life situation. Instead, mental illness is created and sustained by society itself. In his book Outsiders, Becker (1973, p. 9) sums it up this way: Social groups create deviance by making rules whose infraction constitutes deviance, and by applying those rules to particular people and labeling them as outsiders. From this point of view, deviance is not a quality of the act the person commits, but rather a consequence of the application by others of rules and sanc- tions to an “offender.” The deviant is one to whom that label has been successfully applied; deviant behavior is behavior that people so label. Essentially, then, chronic mental patients are victims of labeling and differential treatment by others and would not be chronic patients otherwise. There is a more subtle process by which mental illness labels can have delete- rious consequences. In his “modified labeling theory,” Bruce Link (1987; Link, Cullen, Frank, & Wozniak, 1987) has argued that outright rejection and discrim- ination by other people are not necessary for a self-fulfilling prophecy to occur. Instead, persons who have been diagnosed and hospitalized are well aware that negative stereotypes of mental patients are generally held by the public (Link et al., 1999). These stereotypes take on acute personal significance once the patient has https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  122 Peggy A. Thoits been discharged back into the community. Because the former mental patient expects rejection and discrimination from other people, he or she engages in at least one of three coping strategies: (1) avoiding contact with other people, (2) concealing information about his or her psychiatric past, and (3) attempting to educate others about mental illness to combat their stereotypes. Link shows that these strategies tend to backfire, leaving former patients isolated, demoralized, and distressed and with fewer employment opportunities. Thus, expectations of rejection are sufficient to start a negative self-fulfilling process, regardless of the actual reactive behaviors of other people. Link and Phelan’s Chapter 29 elaborates on labeling theory, presenting the evi- dence both for and against various tenets of the theory. For now it is sufficient simply to point out that there are several limitations to and problems with the theory in its original formulation. Clearly, classic labeling theory best applies to patients who have been involuntarily committed to treatment and to those who have become chronically ill. Because a majority of patients seek treatment voluntarily (Pescosolido, Gardner, & Lubell, 1998) and most episodes of disorder are short- lived, the theory has limited explanatory power. The theory does not explain how or why individuals voluntarily self-label and seek treatment (although see Thoits, 1985). It tends to ignore the crucial role of informal labeling by family members and neighbors; mental patients are usually brought to psychiatric attention through the tentative preliminary labeling of these “unofficial” agents of social control. Also problematic are two implicit assumptions of the theory. One is that a behav- ior or symptom will usually stop if it is not labeled. This is an assumption that flies in the face of casual observation as well as considerable evidence. The other problematic assumption is that labeling and differential treatment are the key causes of continued psychiatric symptoms (Scheff, 1984); this implies that the initial causes of psychological symptoms (biological, psychological, sociological, and so on) cease to have major influences on the individual’s thoughts, feelings, or behaviors after labeling has occurred – which of course is not a sensible implica- tion. In short, the theory in its original form probably overestimated considerably the importance of labeling as a cause of sustained mental disorder. Link’s modi- fication of the theory supplies a more realistic account of how fears of rejection and discrimination can start a harmful self-fulfilling process. Although flawed, labeling theory still has major advantages. Perhaps most important, it has sensitized psychiatric social workers, psychiatrists, and judges to the potential for bias or error in diagnostic judgments when patients are poor, female, elderly, or minority group members (i.e., low in power and status). Relat- edly, state laws have been revised to make involuntary commitments more diffi- cult, giving the accused access to legal representation and ensuring that involun- tary hospitalization lasts no longer than so many days without a formal review (Gove, 1982). Labeling theory has also made policymakers and hospital adminis- trators more aware of the problem of “institutional syndrome,” in which long-term https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  Sociological Approaches to Mental Illness 123 patients become overly dependent on hospital staff, unable to care for themselves, and passive and compliant as a result of their hospital experience. One of the goals of the deinstitutionalization movement was to prevent institutional syndrome by moving patients back into the community before they became overly dependent on the hospital. Labeling theory is especially valuable because it reminds us that mental illness is, to some extent, socially created and sustained and that there are risks to accepting psychiatrists’ judgments as invariably valid assessments of mental disorder. Wrongful commitments can occur and societal reactions based on stereotypes can make the experience of disturbance more severe and potentially more long-lasting. Finally, strong evidence for the existence and negative effects of stigma has accumulated. The treatment implications of labeling theory are quite different from those of stress and structural strain approaches. Potential ways to reduce or prevent men- tal illness include changing social norms that define “normal” thoughts, feelings, and behaviors; attacking widely held misperceptions of the mentally ill; avoiding the formal diagnosis and hospitalization of individuals for aberrant behavior; and reducing the length of stay of hospitalized individuals to prevent them from acquir- ing a deviant identity. Although many of the treatment and preventive implications of labeling theory seem overly idealistic – you will learn more about the (mostly negative) consequences of deinstitutionalization in Part III of this volume – the theory remains important for its sensitizing, critical perspective on psychiatric diagnosis, mental hospital life, and the stigma attached to mental illness, which is as strong today, if not stronger, than 50 years ago (Pescosolido et al., 2008b; Phelan, Link, Stueve, & Pescosolido, 2000). Integrating the Three Sociological Theories By this point, the careful reader might see how the three dominant sociological explanations of mental illness could be integrated. Structural strain theories sug- gest that the ways in which societies, institutions, and neighborhoods are organized create general patterns of advantage or risk for particular social groups. Stress the- ory bridges the gap between macro structures and micro (i.e., individual-level) experiences by explaining how structured risks become actualized in the lives of individuals as stressful experiences. According to stress theory, when events and strains accumulate in people’s lives, they can overwhelm people’s psychosocial resources and abilities to cope and then generate symptoms of psychological disor- der (primary deviance, in labeling theory’s terms). Labeling theory picks up at this point and suggests that frequent, severe, or highly visible symptoms, or symptoms exhibited by those with little social prestige or power, can launch a victimiz- ing process. Societal reactions to symptoms may result in the person’s receiving a formal psychiatric diagnosis, becoming hospitalized, and, ultimately, accept- ing a mental patient identity. Alternatively, fears of rejection may lead former https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press  124 Peggy A. Thoits psychiatric patients to adopt dysfunctional coping strategies that perpetuate their isolation and disturbance. As mentioned earlier, however, evidence shows that chronic patienthood is not an inevitable consequence of labeling processes, despite the assertions of labeling theorists to the contrary (e.g., Scheff, 1984). Explaining how and why the majority of people who have been diagnosed and hospitalized do not become chronically mentally ill is the next theoretical task for sociologists to tackle. Concluding Commentary It is important to remember that sociological theories of etiology do not claim to explain fully the causes of mental illness. No single approach to mental illness – biological, psychological, or sociological – can completely explain its origins. For example, even if deficits of certain neurotransmitters in the brain were shown to be directly responsible for major depression (a biological explanation), the onset of a depressive episode is probably due to multiple factors operating simulta- neously: a person’s gender, age, social class, current stressful experiences, past unresolved psychological conflicts, and a strain-producing structural context. Each broad theoretical approach to mental illness tends to focus on only certain kinds of causes (biological, psychological, or sociological ones), and thus each approach inadvertently deemphasizes the importance of other causes. Although we focus on sociological approaches in this volume, the intention is not to downplay the importance of other causal factors. Instead, the goal is to deepen and elaborate your appreciation of the sociological factors involved in the causes, consequences, treatment, and prevention of mental illness because these sociological factors are the most likely to be ignored or neglected in the field of mental health in general. Mental illness is not randomly distributed in the population, but is socially pat- terned. Patients in treatment are not a random set of individuals, but once again are socially patterned. Effective treatments, excellent hospitals, and beneficial com- munity services are not equally available, but yet again are socially patterned. Grasping the impact of these social inequalities in the experience of mental dis- order, in the quest for treatment, and in the availability of mental health services is crucial for a well-rounded understanding of the causes and consequences of mental disorder. https://doi.org/10.1017/CBO9780511984945.009 Published online by Cambridge University Press