As Link and Phelan (1999, p. 482) point out, theory and research on stigma has been closely intertwined with the debates over the labeling perspective in sociology. This realization is perhaps best detailed in Being Mentally Ill: A Sociological Theory (Scheff, 1966). In this work, Scheff begins by mapping the lines of agreement and disagreement with other theoretical models (e.g., psychoanalytic, medical, Marxist, biocultural, psychological) of mental illness. Unlike Goffman, however, who ultimately rejects much of the sociological use of the term "deviance" (1963, Chapter 5), Scheff finds a critical start there, particularly as articulated in the work of Howard Becker (1963) and Edward Lemert (1951; 2000). Deviance, from the standpoint of this alternate perspective, is less usefully seen as an inherent quality or characteristic of any act. Rather, deviance lies in people's reaction to any act or behavior. Thus, Scheff takes as central the distinction between rule-breaking and deviance; that is, the difference between violations of social norms and the subset that becomes officially labeled as norm violations.
Basic to Scheff's labeling theory of mental illness is a solid description of the underlying social process that leads to chronic mental illness, combined with a detailed accounting of the contingencies that shape societal reactions. As depicted in Figure 13.1, the process begins with norm violations or "offensive acts" in the context of a particular social setting. Many norm violation acts have readily available categories into which they may be classified; for example, crime, perversion, or bad manners. The potential for being labeled with a mental illness comes when behavior or appearance does not fit existing categories, becoming "residual rule breaking" or "residual deviance."
Here Scheff outlines three basic propositions: rule-breaking is 1) diverse in origin - psychological conditions, defiance or resistance, and biological changes, for example; 2) very prevalent compared to treated rates of mental illness; and 3) most often unnoticed, rationalized away, or denied. Further, whether or not the residual rule-breaking is noticed depends on a complex interplay of contingencies that shape the reaction of others to individual behavior. The severity, visibility and frequency of the rule-breaking all push toward a more severe reaction, as do the existence of cultural biases and stereotypes that predispose a judgment of mental illness (e.g., the depressed housewife). However, rule-breakers who have social power are likely to be protected from negative responses by taking an alternative role or label for behavior (e.g., the eccentric millionaire). Finally, the social distance between the rule-breaker and those observing the behavior matter: When the target person occupies the lower
Social Category OFFENSIVE ACTS Available
(primary deviance) ^^ No Other Social Category Available
Severity of Societal Reaction t
(secondary deviance) Breaking ^
Figure 13.1. Depiction of the labeling process (Scheff, 1966).
Denied social status and is observed in transgressions by those with greater social power, the probability of a negative societal reaction is increased. In the end, the constellation of contingencies surrounding a behavior or appearance results in a societal reaction.
Much residual rule-breaking is ignored at this point, having only transitory import. However, if the outcome of the interactional process is a severe societal reaction, then the individual is labeled "mentally ill" and enters into a positive feedback loop. That is, because culture holds images in language and media of what "appropriate" behaviors are for persons with mental illness, the labeled individuals begin to act in conformity with that label, engaging in more residual rule-breaking (secondary deviance), solidifying the societal reaction and the "just" application of the label. Since labels define for others and for the targeted individuals what persons with mental illness are "like," labels become potent influences. Stigma is one price to be paid for mental illness.
Not surprisingly, the reaction to labeling theory was anything but quiet. In fact, as discussed in the "Introduction" to this volume, much of the attention in the mainstream sociological journals that addressed the sociology of mental health revolved around the debates about the power of labels. Prominent among those who opposed the idea that mental illness and the subsequent reaction are socially constructed was Walter Gove. In a series of articles, Gove and his associates argued that the societal reaction perspective is largely a theoretical exercise accompanied by very little empirical data. Further, Gove found that existing empirical data that could address the power of labeling theory also called the perspective into question. He contended that individuals who are hospitalized, indeed, have a "serious disturbance." In addition, the idea that a label sets in motion a self-fulfilling prophecy that shapes future behavior or an individual's fate, he argued, was at best over-blown (Gove, 1970). In fact, Gove and Tudor (1973) concluded that their data show that when biases suggested in labeling theory are taken into account (e.g., greater likelihood of women to offer socially desirable responses), the difference in rates of mental illness between men and women actually increase (see also Gove & Howell, 1974). In support, Dunham (1971) argued that labeling theorists "turned their backs on two centuries of clinical data collected by psychiatrists" (1971, p. 313) and failed to understand "the consequences of hospitalization, especially in the new climate of hospital treatment for mental illness" (1971, p. 313). Thus, opponents of labeling theory rejected what they considered to be an extreme social constructivist view, even as they disagreed about the effects of the aftermath of hospitalization on individuals' futures.
This critique was also contested. A number of individuals saw Gove as misinterpreting their research (Mechanic, 1971) or misunderstanding the theory itself (Scheff, 1974). As Link and Phelan (1999) point out, stigma was a central point of disagreement in these debates. Those opposing labeling theory argued that stigma was "relatively inconsequential" (1999, p. 483), while others continued to find negative attitudinal responses to mental illness and effects on unemployment. In the end, Link and his colleagues (1989) offered modified labeling theory (MLT) that argued that while labeling does not always produce an acceptance of the diagnosis and automaton-like behavior in line with cultural stereotypes, it certainly has important consequences, including stigma (see also Pescosolido, McLeod, & Alegria, 2000, pp. 418-420). According to MLT, cultural stereotypes of mental illness create powerful expectations of devaluation and discrimination in people with mental illness, and these expectations have important consequences for self-esteem, treatment seeking, and social functioning. Studies of consumer populations continue to show that while treatment may have positive effects on individuals' quality of life, stigma continues to produce adverse effects (Link, Struening, Rahav, Phelan, & Nuttbrick, 1997; Rosenfield, 1997).
The labeling tradition continues to shape how sociologists see the effects of mental illness, though its influence on research has focused almost entirely away from its role in shaping diagnosis. As a useful perspective on stigma, labeling theory suggests that devaluation of individuals is fundamentally attached to the acquisition of a diagnosis, even if the presence of "strange" behaviors plays a clear role in conferring and disclosing the "mark" (Martin et al., 2000). The attitudes and behavior of others towards the stigmatized person comprise the prejudice and discrimination that persons with mental illness face. However, the impetus for understanding the role of cultural climate has always had a tie to the study of public attitudes, most notably, sociological attention to race and race relations.
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