Being Mentally Ill: A Sociological Theory

BEING MENTALLY ILL Third Edition

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BEING MENTALLY ILL A Sociological Theory (Third Edition)

Thomas

J.

Scheff

ALDINE DE GRUYTER

New York

About the Author Thomas J. Scheff is Professor Emeritus of Sociology, University of California, Santa

Barbara. He is author of Emotions, the Social Bond, and Human Reality; Bloody Revenge; Catharsis in Healing, Ritual, and Drama; and coauthor of Emotions and Vio­ lence.

Copyright© 1984, 1999 Thomas]. Scheff. First edition 1966 Second edition 1984 Third edition 1999 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, record­ ing, or any information storage or retrieval system, without permission in writing from the publisher. ALDINE DE GRUYTER A division of Walter de Gruyter,Inc. 200 Saw Mill River Road Hawthorne, New York 10532 This publication is printed on acid free paper

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Library of Congress Cataloging-in Publication Data Scheff, Thomas]. Being mentally ill: sociological theory /Thomas]. Scheff. - 3rd ed. p. em. Includes bibliographical references and index. ISBN 0-202-30586-4 (cl.: alk. paper) -ISBN 0-202-30587-2 (pa.: alk. paper) 1. Mental illness-Etiology-Social aspects. 2. Mental illness. 3. Social role.I. Title. RC455 .S25 1999 362.2-dc21

Manufactured in the United States of America 10 9 8 7 6 5 4 3 2 1

99-045679

Conten ts

ix

Preface

PART I

2

I NTRO D U CTION

B i ol ogical Psych i atry and Label ing Theory

3

Effectiveness of Psychoactive Drugs Placebo Reactions Are Psychoactive D rugs Safe? Cha l l engi ng the R u l e of B iopsych iatry The Emotional/Re l ational World Gave's Critique of the Label i ng Theory of Mental I l l ness

6 7

I nd ividual and Soci a l Systems i n Deviance

PART II

3

8

10 13 15

17

TH EORY

Soci al Control as a System

31

Areas of Socia l Control The Soc ietal Reaction to Deviance Concl usion v

40 45 50

vi

Contents

4

Residual Deviance

53

The Origins of Residual Rule- B reaking Preva l ence The Duration and Consequences of Resid ual R u l e-Breaki n g

5

The Soc i a l I nstitution of I nsanity I nd ividual an d I nterpersonal Systems in Rol e-Playing Learning and Mainta i n i ng Role I magery N ormal i zation and Labeli ng Acceptance of the Deviant Role A N ote on Feedback i n D eviance-Amp l ify i ng Systems Conclusion

PART Ill

6

65

69

70

74 84 86

94 97

T H E POWER Of T H E PSYCH I AT R I ST

D ecisions in Med i c i ne Type 1 and Type 2 Errors Dec i si on Ru l es i n Med i c i ne Basic Ass u m ptions The " Si ck Role" I m p l ications for Research

7

58 63

Negotiat i ng Rea l i ty: Notes on Power i n the Assessment of Responsib i l i ty The Process of Negotiation A Contrasting Case D i scussion Concl usion: Negotiation in Soc ia l Science Research

101

1 03 104 106 108

110

115 120 123 12 6 130

Contents

PART I V

8

T H E EMOTIONAL/RELATIONAL WORLD

A Psychi atric I n terview: A l ienation between Patient and Psych i atrist Soci al Action and Natural Language Example of I nteraction Ritua l : The Opening Exchange i n a Conversation Embarrassment and Anger: The Feel i ng Trap of Shame-Rage I nterpretation and Context I m p l i catu re, Context, and Soc ia l Structure

9

Label i ng i n the Fam i ly: H i dden Shame and A nger Pri de, Shame, and the Soc ia l Bond A New Label i ng Theory Labe l i ng i n the Fami ly: A Case Study (Based on Scheff 19 89) Label i ng by Psyc hiatrists Concl usion

PART V

10

13 5 13 6 139 141 14 5 1 52

157 1 59 161 161 171 1 72

SUMMARY A N D REVIEW

Concl usion Symptom, Context, and Mean i ng Typi fication i n D i agnosis Mental I l l ness and Soc ia l Status I m p l i cations of the Emotional/Relational World for Treatment and Research

177 177 1 82 188 19 7

Appendix: I m pact of the 19 66 Edition on Legislative Change

20 1

References

203

I ndex

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Preface

The fi rst ed ition of th is book ( 19 6 6) presented a soc iological theory of men­ tal d i sorder. Seeing mental d i sorder from the po i nt of view of a s i ngle d isci­ p l i ne, the theory was one-d i mensiona l. The second edition ( 19 84), except for s l i ght changes, conti n ued i n t h i s same vei n . Si nce that time there have been substantial advances i n the b iology, psychology, and even in the soc iol ogy of mental d isorder. What is now most needed is an i nterd i sc i p l i nary approach, one that wou l d i ntegrate the d isparate l anguages, viewpoi nts, and fi n d i ngs of the rel evan t d i sc i p l i nes. Such an i ntegrated approach wou l d be far greater than the sum of i ts parts, the separate d i sc i p l i nes. In human conduct, partic­ u l arly, the vital processes seem to occur at i nterfaces, in the i ntersections of orga n i c, psychological, and socia l systems. To use E. 0. Wi lson's term (199 8), what we wa nt is "cons i l ience," the i n ­ terlock i ng o f frameworks from t h e rel evant d i sc i p l i nes. A l though not u s i ng that word, I had proposed a s i m i lar i nterlocking for the soci al sciences (Scheff 1997) and i l l u strated what i t wou ld l ook l i ke with severa l of my own stud ies. As W i l son i nd i cates, many of the recent tri u m p h s of the physical and l ife sci ences have been based on the i ntegration of the various d isci p l i nary approaches. As Wi lson al so i nd i cates, there has been very l i ttle consi l i ence among the behavi ora l and soci a l sciences. Each of these d i sc i p l i nes goes i ts own way, ignori ng the adjacent d i sc i p l i nes. Each emphasizes i ts own vi rtues, l argel y ignoring i ts weaknesses, a s i n t h e o ld song: "You got t o accentuate t h e posi ­ tive, e l i m i nate t h e negative, t u n e i n t o t h e affirmative, don't mess w i t h Mr. I n ­ between ." Contrary t o t h e song, w e must begi n t o mess w i t h Mr. l n between . G iven t h e need for cons i l ience, is there a n y poi nt i n resurrecti ng l abel i ng theory, yet another one-di mensional approach to the compl ex problem of

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mental d i sorder? Before preparing this edition, I gave thought to this issue. My dec ision that the theory sti l l h ad val ue was based on the fol l owi ng i deas. Fi rst, wh i l e wa iting for con s i l ient approaches to be developed, headway can sti l l be made with one- or two-d i mensional approaches. As w i l l be proposed i n Chapter 1 , bi opsychiatry, an i ntegration of biology and psych i atry, seems to have made many worthw h i le advances i n the u ndersta n di n g and treatment of mental d isorder. In the last twenty years, even one-d i mensional studies of label i ng of menta l disorder have made contri butions to our u nderstandi ng, as in the work of B ruce L i n k and h i s col leagues. When con s i l ient theories are developed, there w i l l sti l l be a need for approaches that are only one- or two­ d i mensio n a l . A second i dea may b e j ust as i mportant, that o f t h e dev i l 's advocate. B io­ psych iatry, the dominant force in the field, l i ke a l l d i sc i p l i nes, accentuates the pos i tive. Label i ng theory can be cons i dered to be a cou ntertheory, criti­ cal of the weakest poi nts i n the domi nant theory, and focusing on i ssues that it neglects. The two approaches can complement and correct each other, wh i le we are awaiting Mr. lnbetween . The original theory of menta l i l l ness presented i n th i s book had i ts h igh­ water mark in the 1 9 70s, if perhaps only as a cou ntertheory. During that decade label i ng was taken seriously i n soc iology and, to a lesser extent, in a nthropology, cri m i nology, psychology, psyc h iatry, and soc i a l work. Its sta­ tus began to wane i n the next decade, and by the beg i n n i ng of the 1 990s i t h a d been al l but d i s m i ssed b y the mainstream d i sc i p l i nes. As w e shal l see i n C hapter 1 , there are sti l l proponents o f the theory. B u t t h e m ajority o f schol­ ars and practitioners have moved on to other interests. There are two m a i n reasons for the loss of i nterest. The most i m portant i s what i s ca l led popu larly "the tranqu i l i zer revol ution," and t h e accom pany­ i ng rise of b i ological psychi atry. Beg i n n i ng in the 1 980s and reach i ng i ts peak in the m i d-90s, most soc i a l sci entists and practitioners formed the i mpression that the problem of menta l i l l ness had been solved, at least i n princi ple. The p u b l i c was persuaded by c l a i ms that the causes and treatment of mental i l l­ ness had been shown to be b iological. It was thought, and sti II i s by many, that genetic ca uses of mental i l l ness h ad been or wou l d shortl y wou l d be fou nd, and that psychoactive drugs cou l d cure or at least safely control the symp­ toms of metal i l l ness. The first part of Chapter 1 wi l l be devoted to exploring these clai ms. It seems now that a lthough b io logical psyc hiatry has made advances, in the m a i n i ts c la im s have sti l l not been sufficiently su bstantiated. These m atters are too complex to deal with briefly, so they w i l l be rai sed i n the next chapter. A second reason for the dec l i n i ng i nterest i n the theory was various cri­ tiques proposi ng that s i nce l abe l i ng theory was not substantiated by empiri­ cal studies, it should be abandoned. The most i m portant of these critiques were those by Cove ( 1 980; 1 982). As with b iological psych iatry, it now appears

Preface

that the critiq ues of the label i ng theory of menta l i l l ness were overstated. I n Chapter 1, I wi l l respond t o Gave's critique. The earl ier editions of this book were based on stud ies conducted during the period 19 60-19 82. S i nce that t i me, there h ave been many extraord i na ry cha nges i n the fie l d of mental i l l ness: the i ntroduction of psychoactive drugs o n a m assive scale; the d iscovery of the neurotransmi tters; the hope of find­ i ng gen et i c causes of mental i l l n ess; the pro l iferati o n a n d deve l opment of psychologic a l thera pies; changes i n the menta l health l aws governi ng com­ m itment and treatment; and final l y, an i ncrease in the n um ber and scope of soc i a l scientific stu dies of mental i l l ness. ( Fo r a description of the of the fi rst ed ition of th i s book o n menta l health l aws, see the Appendix.) Thi s edi t i on updates the earl ier ones, bringi ng these changes a n d their aftereffects i nto i ts p u rview. I n addition to these changes i n the field s i nce 19 84, there h ave a l so been changes in my own poi nt of view s i n ce the time of the fi rst ed ition. Fi rst1 the changes related to my work on catharsis of emotions, as re­ flected i n the book on t h i s top i c ( 1979). Second1 my stu d ies of the emotions of pride and sharne (Scheff 1990; 1994; 1997; Scheff and Retzinger 199 1) , and the l i nk between these emotions and the state of the soc i a l bond. Th i rd, my i n terest in connecti ng the worl d of everyday l ife to the larger i nstitutions in a society h as d i rected my attention to d i alogue as data (Scheff 1990; 1997). Fi­ n a l l y, mostly as a res u l t of my d i al ogue stu d i es, I now th i n k, l i ke Wi l son (1998), that i t i s i mperative to i ntegrate the separate d i sc i p l i nes that deal with h uman behavior. These changes i n poi n t of view have had three m a i n effects on th i s ed i ­ tion. Fi rst, they h ave led me to more strongly emphasize that t h e o ri g i n a l be! i ng theory o f mental i l l ness, as p resented i n Chapters 3-5, i s o n l y one o f m a n y partial poi nts o f view. Each o f these poi nts o f view i s useful , b u t i n the long run, i t w i l l be necessary to i ntegrate the d i ffering standpo ints, espec i a l l y the psychologica l , soc io l ogical, and b i ol og i ca l a pproaches. The second change i nvolves i nc reased emphasis on emotions and soc i a l bonds. T h e original theory was predo m inantly cogn itive and behaviora l . I n t h i s ed ition/ emotions a n d relations h i ps are i ntrod u ced/ w i th a spec i a l em­ phasis o n the emot i o n of shame as a key component in stigma a n d in the generation of the soci etal reaction to deviance. I now emphasize the rol e of pride/shame a s D u rk h e i m 's "soc i a l emotion," a n d the i n terp l ay of these emotions with soci a l bonds. S i nce emotions and bonds are b i o logical, psy­ chological, and social, i ncreasing emphasis on the emotional/relational world, l argel y i nvisible i n Western c ivi l i zation, may offer a bridge between the d i s­ c i p l i nes. The origi nal l abel i n g theory was b l i n d to the emotional/relational world; i t dea l t only with extremes of societal l abe l i ng and den i a l . In th i s edi tion, I extend t h e theory to i nc l ude more subtle forms of i nteractio n . Two o f t h e new chapters ( 8 and 9 ) i l l ustrate t h e emotional/relational world by apply i ng label i ng theory to the social i nteraction between thera p i st and

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patient. Chapter 8 i nvo lves a psychotherapy session between an anorex ic woman, " R hoda," a n d her therap i st. The patient reports d i scou rse in her fa m i ly, espec i a l l y d i a l ogues between herself and her mother. These d i alogues suggest that l abe l i n g of the patient occurred fi rst i n the fam i ly, before any formal labe l i ng took p lace. Th is chapter poi nts toward a modification and ex­ tension of the original theory. Chapter 9 concerns the first meeti ng between an outpatient, "Martha," and a psych i atrist. I t turns i nto a sparring match between the patient, who want to convey her emotional/relational world, and the psych i atri st, who wants to ascerta i n the facts. Th i s i nterview exactly reverses the situation between ther­ apist and c l ient from that of the session in Chapter 8. In the latter session, it is the therapist who seeks to i nterest the cl ient in her emotional/relational world. In the session in Chapter 9, i t is the patient who tries to i nterest the psych iatrist in her (the patient's) emotional world. Because of her ski l l and patience, " Rhoda's" therapist is successfu l ; she i ntroduces her patient to the world of emotions. Martha's therapist, however, rema i n s obl ivious. With respect to the origi n a l theory of labe l i ng, after due consideration, I deci ded to revise m a i n ly by add ition rather than by mak i ng large changes i n the ori ginal text (Chapters 3-5) . A new Chapter 1 takes u p the i ssues ra i sed above about the perspective of b iological psych i atry, on the one hand, and critiques of label i ng theory, on the other. Because I was u n able to find a very concise statement of the theory of social control, I wrote a new chapter for the second ed ition (Chapter 2), stating the main el ements of soci al control and relati ng them to deviance and to mental i l l ness. I have resisted the temptation to make large changes in the text outl i n i ng the theory that was p u b l i shed i n 19 6 6 because i t may sti l l be usefu l i n i ts orig­ i nal form. S i nce the d iscovery of the ro le of the neurotransmi tters, and the i m petus to geneti c research provided by D NA, researchers who i nvestigate sch i zophre ni a and the other major menta l i l l nesses bel i eve that they are now asking the right questions, and that knowledge of the causes and cu res of the major mental i l l nesses w i l l be u ncovered w i th i n the i r own l ifeti mes. Thi s re­ search, which grew out of the use of psychoactive d rugs, has also convinced many psychiatrists that these drugs not only are i mporta nt in the treatment of mental i l l ness but a lso hold the key to the u ndersta n d i ng and conquest of these problems. These are heady ti mes for biological theories of mental d i s­ order. Although their hypotheses are p lausi b le, they are sti l l, at this writi ng, u n­ proven. To date, no clearly demonstrable l i nkage between neurotransmission or genetics has been fou nd for any major mental i l l ness. The i dea that the menta l ly i l l suffer from deficient neurotransmission or genes i s o n l y a theory. Furthermore, even if the con nection were made, most of the basi c i ssues i n­ volving the social control of mental i l l ness wou ld rem a i n . S i nce the con nec­ tion i s sti l l hypothetical, it is premature to d i scard labe l i ng theory.

Preface

xiii

The same reason i n g appl ies to what has been popu larly ca l l ed the "tran­ q u i l izer revol ution." As wi l l be d i scussed in Chapter 1, even the most usefu l of the psychoactive drugs do not cure mental i l l ness-they a l levi ate the symptoms. And aga i n , even if a drug treatment were fou n d that cou ld cure mental i l l ness, the funda mental i ssues of social contro l wou l d remai n . When the pai n k i l l i ng properties of morphi n e were d i scovered, physicians cal led it "God's own medici ne," because they thought i t was a cure. It took many years to real i ze that it was o n l y a pa i n k i l ler. There may be a para l lel to be drawn between the discovery of morphi ne and that of psychoactive d rugs. It has been less than fifty years si nce the large-scale use of tranqu i l i zers bega n . It m ay sti l l be too early t o eval uate their overa l l effects. I a m not argu i ng that the neurotransmitter hypothesis is incorrect, or that drugs are worthl ess; I a m o n l y suggesti ng that i t i s m uch too early to d i scard l abel i n g theory, desp ite the significant gai n s that have been made. Some bal­ a nce i s req u i red i n eva l uating the competi ng claims of both the somatic and the social theori sts. I n i ts heyday, there was a tendency i n sociol ogy to over­ state the claims of l abeling theory. To avoid overstatement, i n the 1984 ed i­ t i o n I m ade two changes i n t h e origi nal text. Fi rst, I rel i n q u ished t h e "single most i m portant" phrase i n Proposition 9 , stati ng i n stead that labe l i ng is among the most i mportant causes. The issue of the order of i mportance of the various causes i s empirical a nyway and should not h ave been reduced to a theoretical c l a i m . The second cha nge i nvolves q ua l ifying t h e contrast between t h e two poles of the societal reaction. Origi nal ly, I ca l led the reaction to deviance that was opposi te to l abel ing "den i a l "; in t h i s edition I h ave changed it to "normal­ ization." In fact, den i al i s only one of many d i fferi ng ways of react i ng to de­ viance, such as ration a l ization, ignori ng, and temporizi ng. I n the context of mental d i sorder i t i s i mportant to note that treatment is not necessa rily a l abel i n g reaction. Label i ng, in the sense I use it, always in­ volves stigmatization; there i s an emotional response as wel l as special label . Any form of response that does not stigmat i ze, such as ski l lful and h umane psychotherapy and hospita l i zation, may a l so be a form of normal i zation. I n some ways, the term labeling i tself i s perhaps u nfortunate, si nce i t has be­ come fas h ionable to apply it to mere classification. What is needed is a more forcefu l term, one that wou ld con note both l abel i ng and stigmatization, so that a d i sti nction cou l d be made between rei n tegrative and rejectin g classi­ fication, as in B raithwa i te's (19 89) approach to crime contro l . It may help give perspective if I locate t h e labe l i ng theory outl i ned i n t h i s book w i t h respect t o other "anti-psychi atry" approaches, as they have been cal led. Like the viewpoi nts of Coffman (19 59), Laing (19 6 7), and Szasz (19 61 ), the theory i n t h i s book offers an a l ternative to the conventional psych i atric perspective. The basic d i fference from the other a nti-psych i atry approaches i s that I offer an actua l theory of mental i l l ness. That is, I propose a poss ible

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social scientific sol ution to the problem of defin i ng and treating mental i l lness. The theory is made u p of concepts that are at l east partial l y defi ned, expl i c it causa l hypotheses, and app l i cations to real events. Th i s theory is therefore testable, as Gove and others were able to show i n the early critiques of the t heory. A l though GoHman 's approach i s sociologica l l y sophisticated, i t does not contai n a theory of menta l i l l ness. He defines his terms o n ly conceptua l ly, with l ittle attention to the problem of goodness of fit to i n stances. Lai n g's ap­ proach i s psychological l y sophi st icated, b ut i nvol ved even conceptua l development. Szasz, fi nal ly, uses n o concepts; h i s approach is stated entirely in vernac u l ar words. Th i s approach ma kes it easy for anyone to u n derstan d, even l aypersons. But i t is much too narrow and s i m p l ified to use for analyz­ i ng and understa n d i ng actua l cases, each of which is apt to be qu ite comp lex, l ike most human conduct. Szasz m akes the case that the medical model is not appropriate for most cases of what is designated to be menta l i l l ness and therefore that the term menta l illness i tself is i nappropri ate. I agree. But in order to m a ke my argu­ ment u n derstandable, I have resorted to that i nappropriate term in o logy, o n l y because i t i s coin o f the rea l m . I n this book, it sh o uld be u nderstood t h a t every time I use the term mental illness i t shou l d be seen as encased i n quotation marks. My own term i nology involves a soc iological concept, as expl a i ned i n Chapter 3, "residual deviance." Szasz's rel iance on vernacu lar words reduces h i s theory a l most to carica­ ture. For example, the termi n o l ogy that Szasz suggests as an a l ternative to "psychiatric symptoms" i s "problems in l ivi ng." I f adapted, th i s usage m ight h e l p to destigmatize the sufferers . But the p hrase i s m u c h too broad, s i nce it encompasses a vast rea l m of problems. Unrequited l ove, overextens i on of one's credi t, a n d the i ncapacities of o l d age are certa i n l y a l l common l y en­ countered problems of l ivi ng, but they are not the particular types of prob­ lems that are designated as mental i l l ness. lf S zasz had used the termi no l ogy "residual problems of l ivi ng" (problems that don't h ave conventional n ames), he wou l d have come c lose to my sol ution of the prob lem. In any case, a social theory req u ires statements of exp l i c i t hypotheses, a l l of wh ich are couched i n terms of conceptua l and operational defi n itions. The l a be l in g the­ ory provi des these, the other anti psych iatric formu l ations do not. It is my hope that t h i s edition wi l l provide a clear statement of a socio­ logi c al approac h to menta l d isorder, a n d at l east some s ma l l steps toward i n tegrating it with other approaches to the u nderstanding a n d treatment of menta l d isorder.

I INTRODUCTION

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1 Biological Psychiatry and labeli ng Theory 1

A l though the l ast five decades have seen a vast n um ber of studies of func­ tional mental d isorder, there i s as yet no substantial, verified body of knowl ­ edge i n th i s area, comparable, say, t o medical knowledge o f i nfectious d i s­ eases. At t h i s writi ng, there is no rigorous and exp l i c i t know ledge of the cause, cure, or even a coherent classification of the symptoms of fu nctional mental d i sorders (such as sch i zophrenia, depression, or a n x i ety d isorders). S uch knowledge as there is, i s c l i n ica l and i ntuitive. C l i n ical knowledge i n psychi atry and the other mental health therapies i s l arge and i mpressive, but so far has not been formu lated in a way that wou ld be subj ect to verification by scientific methods. During these five decades, most research on mental i l l ness has sought to establ i s h three m a i n contentions: Etiology (causation)

1.

Cl assi fication

2.

Treatment

3.

The cau ses of mental i l l ness are m a i n l y b i ologica l . Types of mental i l l ness can be coherently class i fied (OMS-IV). Menta l i l l ness can be treated effectively and safely with psychoactive drugs.

My argument about these claims wi l l be based on a h ighly selective re­ view of the relevant l iterature. My emphas i s, for the most part, is on those 3

4

B i ological Psychiatry and Label i ng Theory

studies that raise questions about the val id ity of the bi opsychiatric approach . My review i s probably as u n real istica l l y negative as the b iopsychiatric l iter­ ature is u n rea l i stica l l y posi tive. A balanced review i s yet to be m ade (for a re­ cent attempt, see Chapter 3 of Mech an ic 1 999). Many people have the i mpress ion that a l l th ree of the b iopsychi atric goal s have been reached. Artic les b y journa l i sts u sua lly assume a s m uch . I ndeed, most of the artic les publ ished in psych iatric journals at l east i mply that these three goal s are a l ready establ i shed or that they wi l l be esta b l i shed shortly. They are taken for granted. Certa i n ly i n psychiatric practice i t i s now a tru ism that most cases of mental i l l ness should be treated w i th psychoactive d ru gs . I ndeed, many psyc h i atrists argue that i t is u neth ical not to. Their effectiveness and safety is assu med not only by the majori ty of psych i atri sts, but a lso by health mai ntenance organizations, which in i nsuring med ical care, have come to have an enormous say in the practice of psych iatry. Need less to say, ad­ vertis i n g by drug companies cont i n uously bri ngs these a l leged truths before the publ ic. But these assu mptions sti l l have not been proven. The true pi cture i s much more complex. I n a recent edi toria l in the American journal of Psychiatry, a b iological psyc h i atrist (Tucker 1 998) com p l a i ned a bout the th ree goa ls. He argues that the system of classification developed in psychiatry (OMS-IV) does not actu a l l y fit many patients, and that it has only succeeded i n d i stracti ng attention from the patient as a whole. H i s main objection, however, i s that the syndromes outl i ned in OMS-IV are free-standing descriptions of symp­ toms. U n l i ke d i agnoses of d i seases in the rest of medi ci ne, psyc h i atric d i ag­ noses sti l l have no proven l i nk to causes and cures. As Tucker says, making a poi nt about both classification and causation: "Al l of th i s apparent prec ision [in OMS-IV] overlooks the fact that as yet, we have no i dentified etiological [causal] agents for psych iatric d i sorders" (p. 1 5 9). Th i s particular sentence exactly explodes the b iopsych i atric bubble (see a l so Va lenste i n 1 998). Thi s article is especia l l y noteworthy because it appears in the flags h i p jo u r­ nal of the American Psyc h i atric Assoc iation, the m a i n psyc h i atric assoc iation in the U n i ted States, the home cou n try of b iologica l psychi atry. The most widely read of a l l psyc h i atric journals, u n t i l 1 998 i t relentless l y promoted the threefol d objectives of b iological psychiatry. Th i s d i rection now seems to h ave s l i ghtly s h i fted, however, suggesti ng that the domi nance of bi ological psy­ c h iatry may be com ing to an end. A second article chal lengi ng the pos i tio n of biological psychi atry was pub­ ! ished in the same journal soon after the Tucker article, reviewing stu dies that su pport i nterpersonal causation in the origi ns and outcome of mental i l l ness (Lewi s 1 998). Lewi s proposes ten central premises of the i nterpersona l school of psych iatry, and revi ews stu d i es that show the effectiveness of secure a du l t relat i on s hi ps i n u n d o i ng the a d u l t consequences o f destructive chi ldh ood experiences, and the ro le of wel l-function i ng marriages in decreasi ng de-

Biological Psychiatry and Labeling Theory

5

pression. The appearance of the ed i torial and the special article i n the A]P that ch a l l enge fundamenta l tenets of biol ogi cal psych iatry m ay s ignal the beg i n n i ng of the end of i ts domi nance. Even during the years of biological dom i n a nce, there has been a steady stream of stud ies that rai se cruci a l q uestions about each of the three major strands. The status of claims of biological causation and systematic c lassifi­ cat i on have al ways been ambiguous. O bviously there have been significant advances in knowledge about the i n teraction of b i ol ogical and nonbiologi­ cal factors in menta l i l l ness. A representative study of rates of occurrence of sch i zophrenia i n F i n n i s h twi n s can serve as an examp l e (Tienari and Wyn ne 1 994). Tienari a nd Wyn ne fou n d that the rate of schi zophrenia i n the "adopted-out" twi n born to a schi zophreni c mother was manyfo l d greater than i n the popu lation at large, suggesting a genetic factor. But on the other hand, even though the rates were h i gh, sti l l most of the adopted twi ns with a sch i zophre n i c mother were not d i agnosed as sch i zophren ic, suggesting a n ongenetic origin. To confirm a genetic cause, even for o n l y one part of those d iagnosed as schizophrenic, the deficit gene wou l d have to be i so lated . Al though stud ies of DNA report prom ising areas of exploration, this step has yet to occur. Li ke the c lai m earlier in the century that psychoanalysis was on the threshold of a breakthrough, the cl ai m of genetic causation seems premature (Grob 1 998). The classifications of psych iatric d isorders that have been orga n ized i n to the s ucceed i n g DSM versions appear to be l ittle more than attempts to con­ firm c urrent psych iatric practices, rather than empirical stu d i es . E m pi rica l studi es usua l l y show broad d i screpa ncies between d i agnostic and patient symptoms. An examp le i s the study of symptom cl u sters by Strauss ( 1 9 79L a wi dely respected research psychi atri st. H e compared the actual cl uster of symptoms that each of 2 1 7 first-adm ission patients displ ayed with the d iagnostic syndromes. He conclu ded that the c l u sters of 11the vast ma­ j or i ty [of the patients] fal l between syndro mes." That is to say, the symptoms of the large majority of actua l patients do not cohere the way the DSM or­ gan i zes them, suggesting that, i n t h i s fundamen ta l respect, the problems that psyc h iatrists treat do not seem to fit i n to the medical model of d i sease (al so see Mirowsky 1 990). Researchers from social work have pub I ished two books suggesting that the DSM classifications are determi ned much more by the politics of psychiatry than by evidence ( Kirk and Kutchins 1 992; Kutch i n s and K irk 1 99 7 ) . I n the first book ( 1 992) they show that evidence that wou l d confirm the DSM clas­ s i fi cations is van i s h i ngly smal l . The strongest strand of the biological revol ution i n psychiatry has always been treatment with psychoactive drugs. I n the early years of their use, these drugs were seen as ways of contro l l i ng and dispe l l ing the symptoms of mental i l lness, if not as absolute cures. Especia l l y when compared to psychologica l

6

Biological Psychiatry and Labe l i ng Theory

and soc ial measures, drugs were seen as bei ng cheap, q u i ck, safe, and ef­ fective. There i s sti l l no q uestion about how q u i ck, cheap, and easy to ad­ m i n i ster the drugs are. B u t in the last twenty years evidence that contradi cts the effectiveness and safety of psychoactive drugs has been beco m i n g ava i l ­ a b l e . There are a l so i n d ications that these d rugs m ay b e adm i n i stered to m a n age or control certai n categories of patients, rather than to help them.

EFFECTIVEN ESS OF PSYCHOACTIVE DRUGS

There are a vast n u m ber of systematic studies that seem at fi rst glance to testify to the effectiveness of psychoactive drugs. These are a l most all what i s cal l ed randomized cl i nical tria l s (RCTs), carried out u si n g the standard de­ sign for scientific experi ments. A group of patients with s i m i l a r d i agnoses are d ivi ded random l y i nto two su bgroups. One subgroup, the treatment group, receives the drug, the other, the control group, gets a n i nert substance d is­ guised as a medication, a "placebo." The des ign req u i res that the admi ni stra­ tion of the substances be " b l i n d," that i s, neither the patients nor the doctors know which are the drugs and which p lacebos. If the su bgroups are set up at ra ndom, and if the part i c i pa nts are " b l i nd," then any change in the treatment group l arger than the contro l grou p can be confidently ascribed to the effects of the drug. The usua l l y positive resu l ts of these studies are thought to demonstrate two poi nts: ( 1 ) that psychoactive d rugs are more effective than the pl acebos used in the control groups, and (2) that the i r effectiveness is d ue to the correction of b iological deficits i n the patients. H owever i t is i mportant to n ote that even if these res u lts a re accepted at face va l ue, the average d ifference i n effect between the drug and the p lacebo group i n the typical study i s not large and i s often short-l ived, as shown in stud ies over ti me. Typical ly, i n repeat studies done from fo u r to eight months after the i n it i al one, the average advantage of the treatment group over the control grou p has decreased or even d i sap­ peared. Si nce we are dea l i ng w i th averages a mong many patients, t h i s i s not to say that there a ren't strong positive and negative, and even no effects on i nd ividual patients. To summari ze: even accepting the val id i ty of the RCTs, most psychoactive drugs are o n l y s l ightly and briefly more effective than p lacebos. The decreas ing effectiveness over time i s suggestive of a pl acebo effect. In recent years many studies h ave chal lenged the standard i nterpretation of the RCT studies, that psychoactive drugs, in themselves, are more effective than i nert s u bstances, and that the i r effectiveness i s due to the correction of b iological defic iencies. I t now a ppears that most RCTs are not tru l y b l i nd, be­ cause most of the part i c i pa nts can make accu rate guesses as to whether the patient is receiving a psychoactive drug. Shapiro and Shapiro (1 997, Table 9 . 1 )

7

Pla cebo Reactions

reviewed 2 7 studies that asked doctors, patients, and " raters" (outside ob­ servers) to guess who was receiving the d rug. O n average, 93% of the doctors, 73% of the patients, and 67% of the raters cou l d accurately guess the active agent. Doctors, patients, and raters can use p hysica l effects, taste, color, texture, a n d d issol vabi l i ty to guess. Especi a l l y for t h e patient, t h e p hysica l effects on t h e body often reveal t h e active drugs, s i nce many of them a re powerful sti m u lants, sedatives, or emotion b l ockers. The drug companies who con duct most of the RCTs seldom try to m a ke a c lose match between the drug a n d the p lacebo, because they t h i n k i t i s not sufficiently i mportant to warran t i nvesti ng in the com p l ex task of precise matchi ng. In a scholarly review of this issue, Healy ( 1 997) i s a l so critica l of the u se of RCTs in eva l u at i n g the effects of antidepressants. In my opi n ion, even a carefu l attempt at p recise match in g wou l d face an i nsol ub l e d i lemma. I f the p lacebo were p reci sely enough m atched to the medication, then its own effects on the patient wou l d m a ke the res u lts of the experi ment ambiguous. I t h i n k that experi mental designs that necessitate b l i n d admi n i stration of medici ne a n d p lacebo are i na pp ropriate for h u m a n beings. Case studies a re more appropriate. A lthough they a l so i nvolve rel i a ­ b i l ity problems, they are nearer to t h e s urface. The RCTs h i de val i di ty and re­ l i a b i l ity problems beh i nd the mask of hard science. For a proposal to apply the case study method to the p roblem of eva l uating d rug effects, see Jacobs and Cohen (1999). I f the great majority of the participants a re not truly b l i nd, then the val id­ i ty of the entire method of research i s t hrown i nto q uestion . The p urpose of the RCT design is to r u l e out a l l exp l anations other than the biologica l effect o n the patient. If most of the patients and doctors i n the studies know which medications a re active, the possib i l i ty a ri ses that some or even most of the effects a re psychological and/or social.

PLACEBO REACTIONS

Th i s poss i b i l i ty i s known as "the p lacebo effect." I t has been documented that a l l substances p rescribed by a physician, even if they are i n ert, can have powerful effects on the patient (Fisher and G reenberg 1 997; rlarri ngton 1 997; Shapiro and Shapiro 1 997 ) . The processes that give rise to th is effect a re not wel l u nderstood. I t i s bel i eved, however, that the social psychology of hope, both in the doctor and i n the patient, p l ays an i mportant role. Even in p hys ical i l l ness, the loss of hope can lead to deterioratio n of health i ndependently of the d i sease process. For example, one study of 2 ,400 m i d dle-aged men ( Everson, Goldberg, and Kaplan 1 996) fou n d that hope­ lessness was the best p redi ctor of death from heart d i sease and cance r. Six years after the i n i t i a l i nterview, the 1 1 % of the men with the h ighest l evel of

8

B i o l ogical Psychiatry and Labe l i ng Theory

h opelessness had d ied at three ti mes the rate of the men who were hopefu l . Hopelessness was the best predictor of death o r i l l ness even i n those men who had no prior h istory of heart d i sease or cancer. In mental i l l ness, the effect of hope is probably sti l l greater. Anyth i ng that can i ncrease the patient's hopefu l ness can be potent med icine. I n u nderstand­ i ng the effects of psychoactive drugs on doctors and patients, it is i mportant to remember that before "the tranqu i l i zer revo l ution," many psyc h i atrists be­ l ieved that there was noth i ng they cou l d do to help their patients, espec i a l l y thei r psychotic patients. Perhaps t h e chief effect of these drugs, particularl y the anti-psychotic ones, h a s been on the psych i atrists, restori ng thei r confi­ dence in their own competence, and therefore the i r hope for the patients. The doctor's hope, qu ickly sensed by the i r patients, cou l d i n crease the patient's own hope, and i m prove the relationsh i p between doctor a n d patient, and therefore the whole soc i a l psychology of treatment of mental i l l ness. Of course many, many patients are themselves convinced that they h ave been helped by psychoactive drugs; they feel that the drugs they were given were i n stru mental i n control! i ng thei r psychosis, depression, or anxiety. What i s the harm to them if the help they got, i n most cases, was entirely due to the placebo effect? Th i s issue bri ngs up the q uestion of s i de effects of psy­ choactive d rugs.

ARE PSYC HOACTIVE DRUGS SAFE?

just as p l acebo effects accompany all s ubstances prescribed by physi ci a n s, so also do si de effects . It has been known for many years that some of the w idely u sed anti-psychotic d rugs (neuroleptics), such as Thorazi ne, cause neurological damage, even i n sma l l doses, if they are adm i n istered regu larly (Cohen 1 997). I t i s possi b le that all psychoactive drugs, i nc l u d i ng the m i l dest tranqu i l izers, have potent side effects. The side effects, u n l i ke drug effective­ ness, have not received enough d i rect research attention. S i nce the actions of most psychoactive drugs are comp lex and not u nderstood, patients re­ ceiv i ng them are being exper i m ented on . There are now many studies that demonstrate adverse effects of psychoac­ tive drugs in a sizable m i nority of patients. Tardive dyski nes i a is caused by Thorazine and other s i m i l ar neuroleptics. If adm i n i stered for as l ittle as th ree months, even i n low dosages, these medications w i l l sooner or l ater cause severe neurological damage, tardive dyski nesia . I n th i s syndrome, the patient loses contro l over his body, leadi ng to i nvol u ntary spasms and tics that i m­ pair motor functions. Surpri s i ngly, a lthough th i s s i de effect i s widely known, and m any new neuroleptics h ave been i ntroduced that are supposed to be l ess l i kely to cause it, Thorazi ne and the other offending drugs are sti l l u sed widely (Cohen 1 99 7) .

Are Psychoactive

Safe?

9

Antidepressants have also been shown to have adverse side effects. One study (summarized by Ayd 1 998) showed that these d rugs l ed to profound apathy a n d i nd i fference in 11% of the patients who receive the drugs. A sec­ ond study (Settle 1 998) reported that 20% of 207 consecutive a d m i ssions to a psychiatric hospital had psychoses caused by withdrawal from antidepres­ sants. Surely i n physical med i c i ne any treatment that had such severe and frequent side effects wou l d be peremptori l y suspended from use. It is no longer clear that the benefits of psychoactive d rugs outweigh the costs, even though a majority of psyc h i atrists, a n d a l l drug compan ies and HMOs, have persuaded themselves that this is the case. I n my own observations of persons who take psychoactive drugs, the re­ actions have been variable. In mental hosp itals, by the middle of the eighties, v i rtually a l l of the patients were being given psychoactive d rugs. Most of the patients were receiving at least two d i fferent drugs, some as many as five. Most of the patients I i nterviewed com p l a i ned about adverse effects, h i nting that they d iscarded the drugs. Some showed me how they were able to evade the drugs even if they were given them by n u rses, by "mouthi ng" the d rugs so that they could later d ispose of them. Some of my outpatient subjects were ambivalent about the i r drugs. Two of them had a q u ite s i m i lar reaction to l ith i u m carbonate, a m i neral sti l l wide l y used t o control mood swings i n b i polar (man ic-depressive) i l l n ess. Both re­ ported that the m i neral brought considerable rel ief from their mood swings, but a l so i nterfered with their mental a n d creative capacities. Both elected to disconti n ue. On the other hand, a few of the hospi tal patients, and a majority of the people I knew as outpatients, told me that they were u ndoubtedly helped by thei r drugs, often spectacu larly. I n q uestion i ng them close l y about d rug ef­ fects, I usually found that these subj ects were convi n ced to the point that they were i m patient with m y detai led q uestions. Some rem inded me of persons who had had a rel igious conversi o n . They sang the praises of their drugs, and were not cooperative in respon d i n g to questions. The psychiatrist Aaron Lazare ( 1 989) found that many patients i n the out­ patient c l i n i c he d irected requested tranq u i l i zers, even i n cases when the psychiatrist thought other treatments were indicated. In response, Lazare de­ veloped a protocol he called "the negotiated approach to outpatient treat­ ment," and tra i n ed h i s staff to use it. F i rst the psychi atrist e l i ci ts a request from the patient, with a choice of 14 categories: advice, confession, s u ccorance, venti l ation, and so on. If the patient requested drugs, the psychiatrists were taught to give the patients brief demon strations of alte rnative treatments, such as psychotherapy. Usi ng this method, Lazare's c l i n i c managed to reduce the nu mber of patients on drugs to a level far lower than the average. There is one further problem connected with the biological approach: the way it is used with v u l n erable pop u l ations. It seems l i kely that it is frequently

10

B i o l ogical Psych iatry and Labe l i n g Theory

bei ng used to control or manage chi ldren, confined aged persons, and women, rather tha n to help them. It i s clear that the drug Rita l i n is bei ng used wide l y t o control chi ld re n whom teachers find d ifficult t o manage (Bregg i n 1 998; D i l ler 1 998; DeGrandpre 1 999; Wal ker 1 998). Even a phys i c i a n who pre­ scri bes the i r use admits that they are vastly overused ( D i l ler 1 9 98). Although not condem n i ng the cautious use of Rita l i n, D i l ler, l i ke B regg i n, DeGrand­ pre, and Walker, p roposes that there is an epidem ic of i ndiscr i m i nate use for p roblems that are social or psych ological rather than b iological. There i s a l so scattered evidence that psychoactive drugs a re adm i n i stered i ndiscri m inately to a majority of the elderly who are confined i n conval es­ cent and board and care homes: "[N ] e u roleptic medications are u sed i n 3 9% to 5 1%, of elderly i nstitutional ized patients" (Lancetot et a l . 1 998). These figures refer only to anti-psychotic d rugs. If antidepressants and other tran­ q u i li zers were i nc lu ded, the figures wou l d be much h i gh e r. It may be that psychoactive drugs are being u sed as chemical stra itjackets for a large ma­ jori ty of the confi ned elderly. A sizable n umber of books and articles have protested the way i n which psy­ chiatric diagnosis and treatment systematically discrim inates against women (for reviews, see Brown 1 994; Lerman 1996; Tavris 1 992). It would appear that what wou l d l i kely be ca lled symptoms of mental i l l ness if they occur i n women a re apt to b e i gnored when they occ u r i n men . S i nce the vast ma­ jority of psych i atrists, u nt i l q u i te recently, have been men, fem i nist com­ mentators a rgue that male psychiatrists have usually d iscr i m i nated aga i n st women i n thei r d iagnoses and treatment. They also argue that the DSM c l assification series has d iscri m i nated agai ns t women. For example, sex u a l behavior that wou ld probably b e ignored in m e n h a s been classed a s psy­ chopathy or hypersexual ity in women: [T] he concern over fem a l e autonomy t h a t was i mp l i c i t i n t h e category o f hy ­ persex u a l i ty helps exp l a i n why psy c h ia t r ists consi dered fai l u re to engage i n heterosex ual c o u rtsh i p-whether s i m p l e l ac k of i n terest o r overtly l esbian be­ havior-just as psychopat h i c a s a woma n 's too vigorous exercise of her seduc­ tive powers. ( L u nbeck 1994, p . 522)

Although Lunbeck's comment concerns d i agnostic practices ear l i e r i n th i s century at t h e Boston Psychopath i c Hospital, evidence provided b y B rown, Lerman, and Tavr i s suggest that it i s sti l l relevant to cu rrent practices.

CHAllENGING THE RULE OF BIOPSYCHIATRY

B iopsychiatry so dom i n ates the whole field of mental i l l ness that it i s d i f­ ficu l t to v iew the field from a d ifferent perspective. It i s not easy to locate

Challenging the Rule of Biopsychia try

11

descriptions of practice that do not assume the th ree centra l principles of classification, causation, and treatment descri bed above. To give an a l terna­ tive view, I cal l upon a report by a psychi atrist who su bstituted for a vaca­ t i o n i n g regu lar at a managed care mental health c l i n ic. Th i s psych iatrist has asked that he not be i dentified for fear of reta l i ation: The c l i n ic was privately r u n , b u t it h a d t h e state contract t o provi de t h e local com m u n ity menta l health. I chose not to speak open ly about my views, but to lay low and keep qu iet. . . . I did manage to lower the dose or d i scontinue the medications on most of the patients I saw. I was a lso able to get the court ordered treatment rescinded on one patient, so a l l in a l i i was able to do some good . . . Here's what I learned: The whole mental health system seems to be relying a l most exc l usively on medications. If a patient requests medications, he is given it freely. If he requests any k i n d of counse l i ng or therapy, he has to present h i s request before a review panel that w i l l i n most cases deny t h e request. When a patient was not doing well, everyone looked to me i mmediately to "adjust h i s medications." If t h e patient w a s a l ready adequately med icated, then t h e as sumption was that the patient must not be "compliant." No one ever seemed to consider the poss i b i l ity that the medici nes may not work, even if taken. Nearly every patient I saw was on mu ltiple medications. The majority of patients on Lith i u m and Depakote were not being ade quately monitored with the requ i red blood tests (I d iagnosed 4 cases of l ithium i nduced renal i m pa i rment that should have been detected long before). Tardive Dyski nesia was very prevalent but frequently u n di agnosed or m i sd iagnosed. Even in d iagnosed TD, the offend i ng agent was not d i scontin ued, except in a few cases. Most patients had no idea what medici nes they were taking or why. They take the medic i n e because everyone wants them to, or i n some cases because their cont i n ued SSI, housi ng, and other benefits depended on it. The whole system is i nfant i l i z i ng. Those people who take wel l to being i nfant i l i zed, thrived in it ( i .e., they became fu l ly i nfanti le). Those who d i d n't were consid ered d i fficu lt. I was hai led by the c l i n ic staff and by many patients as a good psych i atrist, mostly because I was the fi rst psychiatrist they had seen who bothered to tal k w ith patients about their real probl ems. Apparently a l l other psychiatrists focus exc l usively on medications and "symptoms." The progress note and psych eva I forms they gave me to complete were fi l l i n-the-blank checkl ists that were ex c l usively symptom oriented. If I wanted to note any sort of psychosocial i ssue ( l i ke the patient goi ng through a divorce, etc.) I had to write it i n the margi n! I thought that pretty much said it a l l . I did a lot of scribbl i ng i n the margi ns i n hopes that maybe someone wou l d read i t and b e i nspired to t h i n k o f the per son as a person, and not just as a set of symptoms.

Although th i s particular observation, based only on one cl i n ic, may not be u niversal l y relevant, i t i s alarming enough to warrant at l east some skepticism about biopsych i atry. It cou ld wel l be the pro mised breakthrough, or it cou l d a l so b e a mere house of cards. I t i s too early t o tel l .

12

B i o l ogical Psych iatry a n d Labe l i n g Theory

G iven the lack of s u bstantial knowledge of d rug act ions and effects, a n attitude o f patient study a n d observation would seem t o be fitting for biopsy­ chiatry at this ti me. A l l too often, however, mere hype is hidden by term inol­ ogy. One example i s the naming of the antidepressant d rugs cal led SSRis (sys­ tem ic serato n i n re-u ptake i n h i b itors), l i ke Prozac, Zoloft, and other s i m i lar drugs. A more modest procedure for naming wou l d be to u se the chemical class these drugs belong to, becau se the name SSRI p rejudges the issue. Al­ t hough there i s s ubstantial evidence that the amount of serato n i n (a neu ro­ transmitter) avai lable to the bra i n is i ncreased by these drugs, it is a l so known that they have many other complex effects, none of which are u nderstood. It i s conceivable that the posi tive d rug effects are not due to seraton i n, or at l east not solely, but to one or more of the other effects (Thase and Ku pfer 1996). G i ven the overal l p i cture of the lack of p roof of genetic causation, the chaos of d i agnosi s, the sma l l average efficacy and dangerous side effects of psychoacti ve d rugs, and the i r abuse in v u lnerable pop u l ations, why hasn't the b i o logical approach been overthrown? The economics of drug use sup­ p l i es part of the answer. It has been extremely profitable for drug compan i es to exaggerate the efficacy of psychoactive d rugs, a n d to p l ay down their brief effectiveness and destructive s i de effects. (For documentation of the drug companies' role in suppressi ng negative evidence, see Bregg i n 1 9 9 1; Ross a n d Pam 1 995; and Healy 1 997.) It has also been p rofitable to the HMOs and to many of the psychi atrists who adm i ni ster them. The m a i n alternative to drugs i s psychotherapy, which i s lengthy and ex­ tremely costly i n comparison, and whose outcome i s u ncerta i n . H MOs much prefer pay i n g $50 to $ 1 00 a month for medications than the at least $ 500 a month that four sessions of psychotherapy wou ld cost. S i m i larly, the psychi­ atrist who d i spenses d rugs can sched u le fou r patients an hour, rather than tak i n g a whole hour for each psychotherapy patient. Bei ng a psychotherapist rather than a p i l l prescriber a l so takes more s ki l l, considerably more patience, a n d exerts more emotional wear and tear on the therapist. Identify i ng the emotional and relational tangles in a patient's l ife is not an easy task, requ i r­ i ng experience, patience, a n d self-confidence. F i n a l ly, psychoactive drugs give psyc h i atrists a competitive edge over other professionals who treat men­ ta l d i sorder, s ince only psych i atrists can prescr i be them . But i n dependently of these i ncentives, there is a l so a powerful demand for drugs from patients and from their fami l ies. Drug treatment upholds the social and emotional status quo; i nd ividual and group psychotherapy ca n threaten it. Psychiatric approaches to the causes and treatment of mental disorder that focus on b iology have been embraced wholeheartedly by the fam i l ies of mental patients who support the National A l l i ance for the Menta l l y I l l (NAMI). To them, b iopsychi atry seems to d i s miss the poss i b i l i ty of fami l i a l causes and changes i n the fami ly system that m ight be req u i red by social and psycho-

The Emotional/Rela tional World

13

l ogical approaches. These fam i l ies h ave b itterly rejected t h e i dea that fam i ly relations h i ps m ay be a cause of their relatives' mental d i sorder. B io l ogical psych i atry, as they i nterpret it, seems to rel i eve them of dea l i n g with shame and gu i l t, and i ndeed from any concern with their own behavior, emotions, and relat i on s h i ps . I t leaves their fam i l y systems, no matter how s l ightly or ex­ tremely dysfunctional, i nv iolate.

T H E EMOT I O NAL/RELATIONAL WORLD

L i ke the dark s i de of the moon, the emotional/relat ional aspects of West­ ern civi l i zation are u s u a l l y h i dden from v i ew. Western societies are h igh l y oriented toward i nd i v i d u a l i s m a n d i nd iv i d u a l achievement (rather t h a n to­ ward groups a n d toward tra d ition, as i n Asi a n a n d other traditional soci eties). Perhaps the c learest exposition of th i s doctr i n e was voiced by the American p h il osopher Emerson, in h i s p h i l osophy of self-re l i a nce. In one of his many paeans to the i ndividual, he said: "When my gen iu s cal l s, I have no father or mother, no brothers or s isters." Thi s i dea i s exact ly opposi te to the rul in g i dea that nothing comes before fam i ly, clan, or n at i o n . in traditional U nwittingl y, Emerson's idea has become o n e o f the m a i n dri v i ng forces i n Western soc ieties. I t prepares c h i l dren for i nd ividual careers, enab l i n g them to be soc i a l and geograp hica l l y mob i le so that they can avai l themselves of opport u nities for achi evement, no matter at what personal and i nterpersonal cost. I t has been one of the m a i n forces lead i ng to the suppression of emo­ tions a n d the ign or ing of person a l re l a t i on s h i ps. O ne's fee l i ngs a n d the q u a l i ty of one's personal rel ation s h i ps do not show u p o n resumes; they are d ispensable. The relational world and its accompanyi ng emotions have come virtu a l l y i nv i s i b l e i n the Western m i d dle-class world. A c lassic example of the rol e of emotional/relational tangles in generati ng psyc h i atric symptoms was provi ded by a psyc h iatrist/soci ol ogist team (Stan­ ton and Schwartz 1 in their study of patients in a mental hospi ta l . U s i ng case h istories of symptom flare-ups, they demonstrated that each a n d every one was due to events i n the patients' soc i a l environment. The feature com­ mon to a l l of their cases, they fou nd, was covert d isagreement among the staff a bout the patient. To u nearth the actual cause of the flare- up took, i n each case, patient and someti mes lengthy i nvestigations. Even then, in the pre­ tran q u i l i zer era, there was cons iderable pressure to attr i bute the flare-u p to the patient's i l l ness, a nd to treat it with med ication. The i dentifi cation and correction of emotional/relational tangles is not a simple task, especially s i nce it someti mes res u l ts i n col l i s ions with the egos of the part i c i pa nts and with the emotional/re l ational status q uo i n the organ i zation or fam i l y. Another example of soc ial/emotional causation of symptom flare-up can be fou nd in Retzi nger's ( 1 989) m i croanalysis of a psychiatric exa m i n at i on of

14

B iological Psychiatry and Labe l i ng Theory

a woman who had been prev i ously d i agnosed as schi zophren ic. Taken from a widely used textbook on the i n itial psychiatric exa m i nation ( G i l l , Newman, and Redl ich 1 954), the flare-up of the patient's del usions i s usua l ly i nter­ preted as an u npredictable outcome of the pati ent's i l l ness. B u t Retzi nger's cl ose exam i nation of the transcript tel ls a d ifferent story. She shows that the psych iatrist's (Fritz Red l ich) manner i n itia l l y was so warm and sympathetic that the patient responded to him i n a patently sane and h uman way. The turn­ i ng poi nt comes when she notices that he has been glancing at the clock. Ap­ parently th reatened by bei ng caught out by a supposed ly i nsane patient, or perhaps worried about who is in contro l, Redl ich's manner abruptly s h i fts. Without warn i ng, he changes from a friend to a relentless d i agnosticia n . He repeatedl y probes and leads, try i n g to u nearth the del usions reported in her record, to the point that she rel apses i nto a delusional state. Retzi nger ca l l s Redl ich's maneuver "reverting t o tech n i q ue," a subtle label ing a n d rejecting of the patient as a person . In t h i s in stance, the psychiatrist u nwitti ngly shamed the patient i nto a delusional state. The labe l i ng that goes on i n " Rhoda's" fam i l y (Chapter 1 0 i n this book) i s also subtle. I n the dialogue between her and her mother that Rhoda reports i n the therapy session, the mother never says d i rectly that Rhoda is menta l ly i l l, but she repeatedly i mp l ies that Rhoda i s not a responsible person . Rhoda must u nderstand this i mplication, because her emotional reactions are i ntense each ti m e it occurs. The transcri pt on which this chapter is based is taken from another wel l -known text, an early m icroanalysis of a therapy session (Labov and Fanshel 1 9 7 7) . Labov and Fanshel's reaction t o t heir own analysis i l l ustrates t h e e l u sive­ ness of the emotional/relational world i n our civi l ization. At the end of the book, they note that if their analysis of the fam i l y d i alogue reported by Rhoda is to be bel i eved, then conflict is perpetual in that fam i ly: every l i ne bristles with covert host i l i ty, rejection, or withdrawal . B u t this i dea troubles the au­ thors, because it i s a lso clear from the d i alogue that Rhoda and her mother are both comp letely un aware of the i r emotional confl ict; they recogn i ze o n l y p hysical violence (Rhoda i s a norexic) . Labov a n d Fanshel raise an astound­ ing q uestion : how cou l d there be conflict if the participants are u n aware of it? Opting to bel ieve the participants rather than the i r own data, Labov and Fanshel d isown their work, the emotional/relati onal world they themselves u ncovered . B i o l ogica l approaches to mental i l l ness support and help perpetuate the h i d i ng of the emotional/relational world. Th is is a Du rkhe i m ian i dea that I w i l l d i scuss further later i n t h i s book. Preservi ng the i nviolab i l ity, the sanc­ t i ty of our avoidance of emotions and relationsh i ps can help exp l a i n the i n­ tensity of the societal reaction to menta l i l l ness. Bi o l ogical psych i atry, i n i ts crude pop u lar form, i s a co l lective representation that serves to mai nta i n the emotional/relational scheme of th i ngs in our soci ety.

Cove's Critique of the Labeling Theory of Menta/ Illness

15

COVE'S C RITIQUE OF THE LAB E L I N G TH EORY OF MENTA L ILLN ESS

I n the seventies and early eighties, Walter Cove (1 980; 1 982) p u b l ished several articles and two h ighly i nfluentia l critiques of l abel i ng theory. He pro­ posed i n these criti ques that the evidence was so overwhe l m i ngly negative that the theory should be abandoned. At least i n mai n stream studies i n soci ­ ology a n d i n related d iscip l i nes, h is recom mendation was nearly carried out. As a res u l t of both the ascent of b iological psych iatry and Cove's and other criti ques, the great m aj ority of researchers in social and medical science h ave vi rtual ly d i s m i ssed l abel i ng theory as a fad of the s i xties and seventies. S i nce Cove's critique has been so i nfluential, I w i l l criti q ue i t in turn, in l ight of the evidence s i nce the t i me that i t was publ i shed . I can not m uch crit­ icize h i s review of the evidence at the t ime that he wrote. With some excep­ tions, the stud ies that sought to apply the theory fou n d l i ttle or no s upport for i t, j ust as he s a i d . A clear a n d exp l i c i t general theory that i s testabl e i s a rar i ty i n the soc i a l sciences. The s u rvival o f general theories l i ke those of Marx and Freud are due, i n least in part, to the i r vagueness. Quantitative re­ searchers, whose forte is enti rely given over to testing hypotheses, rather than generating them, fel l u pon labe l i ng theory ravenously. They were encouraged a l so by the hubris of the ori ginal theorists, who overstated the i mportance of labe l i ng. By now, however, the situation has changed. I n the l ast twenty years, a steady stream of studies h as given a much more m i xed p ictu re. On the one h and, there are sti l l p lentifu l stud ies that ignore labe l i ng hypotheses, reject them on a conceptua l basis, or, i n some cases, once more find negative evi ­ dence. On t h e other h and, there are b y t h i s t i m e a l a rge n u m ber o f studies that cons i stently report l abel i ng effects. The best-organ i zed series has been conducted by B ruce L i n k and h i s col leagues. For the period 1 980 to 1 990, L i n k and C u l l en ( 1 990) report eight of L i n k and h i s col leagues' own p u b l i s hed stud ies, as wel l as those of others; they a l l s how l a be l i ng effects i n menta l i l l ness. More recent studies ( L i n k et a l . 1 99 1 ; 1 992; 1 997) conti n ue i n the same vei n . To b e su re, the conti n u i ng evidence for the l abel i ng theory o f mental i l l­ ness i s sti l l sparse and m i xed: a m i xture of positive and negative findi ngs. However, we now know that the evi dence rel evant to bi ological psychi atry i s a l so m i xed . As a l ready i nd icated, there are now many studies that at least rai se q uestions about the va l id ity of genetic causation, the effectiveness and safety of psychoactive drugs, and the rei iabi I i ty of d i agnostic classifications. There are a l so reasons to doubt the val id i ty of the many studies of effective­ ness and safety of drugs that were produced or sponsored by drug com pan ies (for docu mentation of the exaggeration of positive evi dence and suppression of negative evidence, see B regg i n 1 99 1 ; 1 99 7) .

16

B iological Psych iatry and Label ing Theory

Even acknowledgi ng the i n itial spate of studies that fai led to support the label i ng theory of mental i l l ness, Gave's recommendation that i t be aban­ doned also arose out of the u nfavorable comparison he made between label­ ing and psychiatri c theory. Although h i s assessment of the evidence ava i lable at the time of his critique was mostly sound, his assessment of the va l id i ty of the psych i atric approach was not. He far overrated the coherence of d i ag­ nosis, the effectiveness and safety of drugs, and, i n deed, the val i d i ty of the entire psych i atric approach . G iven what we now know, Gave's view of psy­ chiatry was naive. For th i s reason, it seems to me that the label ing theory of mental i l l ness i s sti l l i n the h u nt. Of cou rse, I am not suggesting that the other theories shou l d be rep laced by label i ng theory, but o n l y that menta l i l l ness, and i ndeed a l l h uman behavior, is sti l l pretty much a mystery; competition between viable theories i s sti l l needed. In the next chapter I wi l l d i scuss so­ c ia l systems and the relational/emotional world, steps toward a con s i l ient (Wi lson 1 998) approach to the problem of mental i l l ness.

NOTE 1 . My thanks to the efforts to remedy deficienci es in my knowledge of biopsy chiatry by Peter Breggin, David Cohen, David Mechanic, Carlos S l uzki, and Douglas Smith.

2 I nd ivid ual and Social Syste ms i n Deviance

One frequently noted defic iency i n psychiatric formu lations i s the fai l u re to i ncorporate social processes i nto the dynam ics of mental d i sorder. A lthough the i m portance of these p rocesses i s increasi ngly recognized by psych iatrists, the conceptua l models used in formu l at i ng research q uestions are basi ca l ly concerned with i ndividual rather than soc i a l systems. Cenetic, b iochem ical, and psychological i n vestigat ions seek d i fferent causal agents but uti l ize s i m ­ i la r models: dynam i c systems that are l ocated with i n t h e i ndividua l . I n these i nvestigations, social processes ten d to be relegated to a s u bs i diary role, be­ cause the model focuses attention on i n dividual d i fferences rather than on the soc i a l system in which the i nd ividual is i nvol ved. Even in the theories that are not orga n i c i n natu re, the soc i a l system is rel­ egated to a rel atively m i nor p l ace in the u n derstanding of menta l i l l ness. Th i s i s true i n psychoanalytic theory, the most i nfluential o f the non-o rgan i c theo­ ries, although Freud and h i s students frequently noted the i m po rtance of the social and cultu ra l I n order to u nderscore the importance o f the system properties of a theory, it is u sefu l to compare psychoanalytic ideas, which are bui lt around i ndividual systems, with Marxist analysis, which is entirely social systemic and exc l udes comp letely any consideration of i nd ividual systems. In psychoanalytic theory, the origins of neurosis are external to the in di­ v i d u a l . Freud's formu l ation was: "The Oedi p u s com p lex i s the kernel o f every neurosis." Fen ichel, Freud's d i sc i p le and chief codifier o f psychoanalytic 17

18

I nd ividual and Soc i a l Systems i n Devia nce

ideas, states: "The Oed ipus comp lex is the normal c l i max of i nfanti l e sexual development as wel l as the basis of all neuroses" ( 1 945, p. 1 08). For gi r l s, the m i rror i mage of the Oedi pa l complex is cal l ed the E lectra complex. Accord­ i ng to th i s theory, a l l c h i l dren pass t h rough a i n w h i ch the parent of the opposi te sex is chosen as a sexu a l object, caus i ng i ntense hosti l i ty and riva l ry toward the parent of the same sex. For c h i l d ren who go o n to become normal adul ts, the Oed i pa l confli ct is resolved: the chi l d rejects the opposi te­ sex parent as a sexual object and i dentifies with the parent of the same sex. The rejection of the parent as a sexual object frees the c h i l d from l ater i n ces­ tuous and therefore gu i l t- laden sexual i mp u lses, and the identification with the same-sex parent begi ns the formation of the superego, which is the very basis for a normal adul t psyc h ic s t ructure. If, however, the opposite-sex parent i s not rejecte� a s a sex object and the same-sex parent not taken as a model, a fu ndamental fau l t is c reated i n the psychi c structure. In th i s case, the person grows i nto an a du l t who is never psychological l y separated from h i s parents: Throughout h is l i fe, he is fighti ng and refighting the Oed i pa l confl i ct. A l l h i s rel ations w i th persons of the op­ posi te sex a re t i n ged w i th i ncestuous g u i l t, because h i s perceptions are based on h i s early ch i l dhood i mages in the fa m i ly. S i m i l arly, a l l h i s re lations with same-sex persons are colored by the hosti l i ty and riva l ry he felt for his parent of the same sex. Accordi ng to thi s theory, the boy who goes through chi ld hood without resolving the Oedipal confl i ct never establ i shes new rel ationsh i ps w ith women or men i n later l i fe but i s i mprisoned with i n the i ncestuous, and therefore psychologica l ly u ntenabl e, relatio ns h i p w ith h i s mother, a n d the hosti le, rival ry-ridden rel ations h i p with h i s father. Fen ichel notes that the soc i a l situation i n the ch i ld's fam i ly at the time of the Oedi pa l confl ict is a key determi nant of whether the confl i ct is resolved. The absence of one of the parents, or the wea kness of one or the other as a model, as wel l as many other conti ngencies, i s a potential cause of l ack of resol ution. I t shou ld be noted, however, that these externa l sources of defect a re no l onger i nvolved i n the neurotic system of behavior after the Oedi pa l stage passes (approx i m ately from the ages of 3-7 years). I f the Oedi pa l con­ flict is not resolved at th i s stage, the psych i c flaw wi l l conti n ue th roughout later l i fe, more or less i ndependently of l ater l ife experiences. It is true that psychoan a lysts do speak of p rec i p i tati ng factors in adult l ife, bu t i t is c l ea r that these factors a re o f o n l y subsid i a ry i nterest. The person i n t h e th roes of the Oedi pa l confl i ct is a defective adu lt, such that stresses that others cou l d easi l y s u rmou nt m ight p lu n ge h i m i nto a fu l l-scal e neuros i s . Thu s t h e psychoanalytic model o f neurosis i s bas i c a l l y a system of beh av­ ior that is contai ned with i n the i nd ividua l . The external s i tuation in which the i nd ividual is i nvo lved is seen o n l y as an a l most l i m itless source of triggers for a ful l y developed neurotic confl i ct w ith i n the i nd iv i d u a l . Psychoanalyt i c the­ ory, l i ke most contem porary theories of mental i l l ness, whether they a re psy-

Individual and Social Systems in Deviance

19

chological or orga n i c, locates the neuroti c system with i n the i ndividual. To be s ure, psychoanalysts, l i ke other psychological theorists, a llow for external causation Fen ichel (1 945) states: The normal person has few ''troops of occupation" rema i n i n g at the position "Oed i p u s comp lex/' to use Freud's metaphor, the maj o r i ty of his troops hav i n g marched o n . However, u n d e r great d u ress they, too, m a y retreat, a n d thus a normal person may become neu rotic. The person with a neurotic d i sposition has left nearly a l l h i s forces at the Oedi p us comp l ex; o n l y a few have advanced, and at the s l i ghtest d i ff ic u l ty they have to go back a n d rejoin the mai n force at thei r first stand, the Oedi p us complex. (p. 108)

S i m ilar di scla imers can be fou n d i n v i rtually a l l the current theories of mental i l lness. Needless to say, i n these theories, as i n psychoanal ytic theory, the d i rection and thrust of the perspective i s fou n d not i n these exceptions and q u a l i fications, but in systemic l i n kages that they posit, connecti ng key characteristics of i nd ividuals with the i r neuroti c behavior. I n psychoa nalytic theory, the great conceptual development occurs i n I i n k i ng the origin s of neu­ rosi s i n the Oedipal stage through the mechani sms of psychosexual develop­ ment to thei r end res u l t, which is treated by the psychoa nalyst theoreticians i n a great wealth of deta i l : the formations of dreams, everyday sl i ps and errors, and fi nally, i n the i r manifold variety and complexity, neurotic symptoms. Many of the critics of psychoanalytic theory have focu sed on just this fea­ t u re as objectionable: the traci ng of the most d iverse ki nds of h u man reac­ tions back to the generic psychological substructure resulting from the Oedi­ pal confli ct. Freud's critics claim that the psychoanalytic model of man i s too tight, narrow, rigid, a n d one-d i mensional. The way i n which psychoanalysts have sought to show how artistic creativity derives from psychosexual con­ fl ict is a case in poi nt. Critics have also objected to Freud's key postulate of the "overdeterm i nation" of symptoms. The I iterature of psychoanalysis abounds i n i n stances show i n g how a symptom i s not s i m p l y a consequence of a si ngle cause but i s merely one aspect of a veritable network of psychic phenomena. It i s for this reason that psychoanalysts are usually adverse to the treatment of symptoms : their theory l eads them to expect that if a symptom i s removed, without changing the basic psychological structure, a new symptom wil l shortly appear i n its place. But critics have objected that psychoa nalytic the­ ory seems to pos i t a type of predestin ation i n which the neurotic is prisoner of h i s i nexorable neurotic system. From the point of v i ew of the construction of a viable scientifi c theory, how­ ever, much of th i s criticism seems m isplaced. It is j ust the "systemness" of psy­ choanalytic theory that m a kes i t such a powerful i ntel l ectual weapon for the i nvestigati o n of neurotic behav i o r. Start i n g from relatively few general pos­ tulates, it develops an enormous nu mber of propositions about very concrete types of behavior. Such a theory is both powerful, i n that i t ram ifies i nto many

20

Individual a n d Soc i a l Systems i n Deviance

areas of behavior, and at least potenti a l l y refutable, so that with an adequate program of empi rical research it cou ld be q u al ified, transformed, or rejected . Furthermore, the notion of the overdetermi nation of symptoms is very much in accord with recent developments in theory construction. I n general systems theory, for example, the idea of overdeterm i nation is closely related to the model of a self-m ai nta i n i ng system. The key feature of such a system i s "neg­ ative feedback," that is, deviations from the system's steady state are detected and fed back i nto the system in such a way as to cause the system to return to its steady state. There is no reason to bel ieve that such a system is fou nd i n only b iological or electron i c rea l ms; psychoana lytic i nterpretations have suggested many ways i n which psychological systems have this property. I n the d iscus­ sion i n the fol lowi ng chapters, a system with self-m a i nta i n i ng properties com­ posed of the deviant and those reacting to h i m wi l l be del i neated. The objection to psychoan a lytic theory that is m ade here is not that i t pos i ts neurotic behavior as part o f a closed system, b u t that t h e system that i t form u l ates i s too narrow, in that i t leaves out aspects of the social context that are vital for understanding mental d isorder. The basi c model u pon which psychoanalysis i s constru cted i s the d i sease model, in that i t portrays neuroti c behavior as u nfolding relentless ly out of a defective psychological system that is entirely contai ned with i n the body. To bri ng the i nd ividual system i c char­ acter of psychoanalytic theory i nto h igh rel ief, i t is i nstructive to contrast i t w i t h Marxi an theory, w h i c h i s soc i a l systemic. Li ke Freud, Marx began h is analysis with relatively few, but highly abstract post u l ates. C h i ef among these post ul ates is the d i ctum that in any society the mode of production determ i nes the basi c soc i a l forms, i n c l u d i ng the econom i c and political systems, the d i rection and pace of soc i a l cha nge, and, u l ti mately, even man's consc iousness. Th i s point is m ade very clearly when Marx states that the mode of prod uction i s the su bstructure and a l l other forms mere superstructure i n a n y soci ety. Marx went o n to construct from this basic premise a theory of h istory and of soci ety in which the char­ acteri stics of i ndividuals are more or less i rrelevant. In h i s anal y s i s of then contemporary Eu rope, Marx pos i ted the acc u m u ­ lation o f capital as t h e process that determi ned soc i a l structure and soc i a l change. I n pri m itive capita l ism, t h e critical step was t h e acc u m u l ation o f suf­ ficient capita l that a man's subsistence was not cont i n u a l l y i n jeopardy. The early capital ist cou ld afford to bargai n for the l abor he h i red rather than ac­ cept whatever the market offered . Society was transformed i nto two cl asses: those who were in a barga i n i ng pos ition (the capita l i sts) and those who were not (the workers). In the course of barga i n i ng, the market rates for l abor i n­ evitably assu med the bottom l i m it, the cost of the worker's subsistence, and the capita l i sts, by the same l ogic, i nevitably waxed rich at the worker's ex­ pense. For our pu rposes, the i nteresting feature of Marx's theory was the man­ ner i n which i t disregarded the motivations of the i nd ividuals i nvolved. For

Individual and Social Systems in Deviance

21

the capita l i sts, for examp le, i t d i d not matter whether they were h u m a n i ­ tarian or not for t h e develop ment o f t h e cap ita l ist system. A capita l i st, who, for h umane reasons, refused to expropriate the workers, wou l d h i mself be expropriated by other capita l i sts. Marx and h i s fol l owers felt that they h ad evolved a theory that was i ndependent of the psychology of i nd ividuals. From these consi deratio ns, Marx (1 906) stated the l aw of capital accu­ m u l ation : But a l l methods for the production of surpl us value are at the same time meth­ ods of acc u m u l ation: and every extension of acc u m u l ation becomes aga i n a means for the development of those methods. It fo l lows therefore that i n pro portion as capital accumu lates, the lot of the laborer, be h i s payment high or low, must grow worse. The law, fi nally, that always equ i l i brates the relative sur pl us popu l ation, or i n d ustrial reserve army, to the extent and energy of accu mu lation, this law rivets the laborer to capital more fi rmly than the wedges of Vulcan did Prometheus to the rock. It establ ished an acc u m u l ation of m i sery, corresponding with accu mu l ation of capital . Accu m u lation of wea lth at one pole is, therefore, at the same time accumu lation of misery, agony of toi l, slav ery, ignorance, brutal ity, and mental degradation, at the other pole. (pp. 708 709)

Marx (1 906) notes the soc i a l and psychological effect of th i s process on the i nd ividual l aborer: Within the capita l i st system a l l methods for ra i s i ng the social productiveness of l abor are brought about at the cost of the i nd ividual laborer; a l l means for the development of production transform themselves i nto domi nation over, and exploitation of, the producers; they muti l ate the l aborer i nto a fragment of a man, degrade h i m to the level of an appendage of a mac h i ne, destroy every remnant or charm in h i s work and turn it i nto a hated toi l ; they estrange from h i m the i ntel lectual potentia l ities of the labor process i n the same proportion as science is i ncorporated in it as an i ndependent power; they distort the con d i tions u nder which he works, subject h i m during the l abor process to a des potism the more hatefu l for its mean ness; they transform h i s l i fe time to a work i ng ti me, and drag h i s wife and c h i l d beneath the wheels of the Juggernaut of capital . (p. 708)

Beg i n n i ng with the dyna m i cs of the economic system, Marx developed p roposi ti ons that led f i n a l l y to a p red iction of psychological con seq uence for i nd ividuals. The statement concern i ng estrangement from the i ntel lectual potential i ties of l abor, together with other s i m i lar statements, i s one basi s for cu rrent formu l ations about a l ienation, a psychological condition that is of great i nterest i n current soc i a l science. For the purposes of t h i s d i scussion, the fai l u res of Marxian theory are not as i mportant as the general form i t takes. The rise of effective i n dustrial u n ions v it iated Marx's a n a l ys i s near i ts prem i se, the i rrevers i b i l i ty of the l aw of

22

I nd i v i d u a l and Soci a l Systems i n Devia nce

capital accumulation. The form of his theory, however, provides an example of a soc i a l system ic model that does not incl ude a ny aspects of i ndividual systems of behav ior. The q uestion rai sed by this comparison i s this: can we for m u l ate a theory that somehow i ntegrates both the i nd ividual and soc i a l systems o f behavior? Several sociolog ists and psychiatri sts developed an approach that gives more emphasis to social processes than does traditional psych iatri c theory yet does not entirely neglect i ndividual aspects. Lemert ( 1 9 5 1 ), Erikson ( 1 95 7), and Goffman ( 1 among soci ol og ists, and Szasz ( 1 9 6 1 ) and Lai ng a n d Esterson ( 1 964), a mong psych i atrists, have contr i buted notably t o this ap­ proach. Lemert, particu larly, by rejecti ng the more conventional concern with the ori g i n s of mental symptoms and stressin g i n stead the potential i m portance of the societal reaction in stabi l i z i ng ru le-break i ng, foc uses primar i l y o n mechan isms of social control. T h e work o f a l l these authors s uggests research avenues that are a n a lytical ly separable from questions of i ndividual systems and poi nt, therefore, to a theory that wou l d i ncorporate social processes. I n h i s d i scussion of gamesmanship, Berne ( 1 964) offers an analys i s of al­ cohol i sm that i s based on a social system model rather than on an i ndividual system model of a lcoholism: I n game a n a l ys i s there i s n o s u c h t h i n g as a l cohol i s m o r " a n a lcohol i c," but there is a rol e cal led the Alcoh o l i c i n a certai n type of game. If a b i ochem­ ical or physi o l ogical abnorm a l i ty is the prime mover in excessive d r i n k i ng­ a n d that i s sti l l open to some q u estion then its study in the fie l d of i nterna l medi c i ne. Game a n a l y s i s is i nterested in somet h i n g qu i te d ifferent­ the k i nds of soc i a l transacti o n s that are related to such excesses. H e n c e the "Al cohol i c ." I n its ful l flower th is is a five-h a nded game, a lthough the roles may be con­ densed so that it starts off and termi nates as a two- handed one. The centra l role is that of the A l cohol i c-the one who is " i t"-played by W h i te. The ch ief sup­ porting ro le is that of Persecutor, typ ica l l y p layed by a member of the opposite sex, usua l ly the spouse. The t h i rd rol e i s that of Rescuer, usua l l y p l ayed by some­ one of the same sex, often the good fam i l y doctor who is i nterested in the pa­ tient and a lso in d r i n k i ng problems. In the c lass i c a l situation the doctor suc­ cessful l y rescues the a lcoho l i c from h i s habit. After W h i te has not taken a dri n k for six months they congrat u late each other. The fol lowi n g day W hite i s fou nd i n the gutter. The fourth role is that of the Patsy, or D u mmy. In l iterature th is is p l ayed by the d e l icatessen man who extends credi t to W h i te, gives h i m a sandwich o n the cuff and perhaps a cup of coffee, without e ither persecuting h i m or tryi n g to rescue h i m . In l ife t h i s i s more frequently p l ayed by W h i te's mother, who gives h i m money and often sympathizes with h i m about the w i fe who does not u n­ derstan d h i m . In this aspect of the game, Wh ite is requ i red to acco unt i n some p l a u s i b l e way for h i s need for money-by some project in which both pretend to bel ieve, a l though they know what he is rea l l y goi n g to spend most of the

Individual and Social Systems in Devia nce

23

money for. Sometimes the Patsy sl ides over i nto a n other role, wh i c h is a help­ f u l b u t not essential o n e: the Agitator, the "good guy" who offers s u p pl i es with out even b e i n g asked for them: Come have a d r i n k with m e (and you wi l l go down h i l l faster). The a n c i l l a ry p rofessional i n a l l d r i n k i ng games is the bartender or l iquor cl erk. In the game "Alcohol ic" he p l ays the fifth role, the Con nection, the di­ rect source of s u pp l y who a lso u nderstands a lcoho l i c ta lk, and who i n a way i s t h e most meani ngfu l person i n the l i fe o f any addict. The d i fference between the Connection a n d the other p l ayers is the d i fference between profession a l s a n d amateurs i n a n y game: t h e professional knows when to stop. At a certa i n point a good bartender refuses to serve t h e A l cohol ic, who i s then l eft without any supplies u n less he can locate a more i nd u l ge n t Con nectio n . (pp. 7 3 74)

Berne seems t o b e suggesting that the dynamics of a lcohol ism have less to do with the motivations a n d traits of the a l coho l ic than with the i n teractions between the occupan ts of the five i n terpersonal positions that he describes. According to his analysis, a lcohol ic behavior is understandable only as an i n tegral part of an i n terpersonal system. A critique of the use of the medical model in psychi atry that parallels many aspects of the present discussion has been made by learni n g theorists in psy­ chology. A thorough and wel l-docu mented statement can be found in the i ntroduction to Case Studies in Behavior Modifica tion (Ullman and Krasner 1 96 5 ) . The psychological model that is p roposed as an a l ternative to the medical model i s based on the sti m u l u s-response a rc. The resu l tant processes of d iagnosis and treatment have been descri bed s i mp l y by Eysenck ( 1 959): " Learn i ng theory does not post ulate any such 'u nconscious cause,' but re­ gards neurotic symptoms as simple learned habits; there is no neurosi s u nder­ l y i n g the symptom, but merely the symptom i tself. Get rid of the symptom and you have el i m i n ated the neurosis" ( 6 1 -75; quoted i n U l l man and Kras­ ner 1 965). The approach to mental d isorder proposed by these researchers appears to be superior to the med ical model in three ways: Fi rst, it is behav­ iora l and therefore a l l ows for empirical research. Second, it i s related to a systematic a n d expl icitly stated body of propositions (i .e., learni ng theory). Final ly, it i s s upported by a sizable body of empi rical studies. It seems c lear that this approach has made important contri butions to psychiatric theory and practice and is l i kely to lead to fru itful work in the future. At the same ti me, it should a l so be noted that "behav ior mod ifi cation," i n practice, tends t o b e used as a n i ndividual system model o f mental d isorder. Conceptu a l l y, this i s not necessar i l y the case. U l l ma n n and Krasner concep­ t u a l i ze psychiatric symptoms as maladaptive behav i or. They go on to say that the goal of treatment of maladaptive behavior should be to change the pa­ tient's relationship to environmental sti m u l i . Thi s formu l ation does not pre­ j udge the question of whether the relationsh i p shou ld be changed by chang­ i n g the patient or the environment. But i n l isti ng the tech n iq ues u sed i n

24

I nd i v i d u a l a n d Soc i a l Systems i n Deviance

behavior modification, i t is dear that the target for these tech n i q ues is the patient. Such techniques as "assertive responses, sexual responses, relaxation responses, conditi oned avoidance responses, feed i n g responses, chemother­ apy, expressive therapy, emotive i magery, in vivo presentation of disruptive sti m u l i, model i ng, negative p ractice, sel f-disclosure, ext i n ction, selective positive rei n forcement, and sti m u l us deprivation and satiation" are the major techn iques l i sted by U l l ma n n and Krasner. These tech niq ues are oriented to­ ward changi ng the patient's psychological system rather than the i n terpersonal o r social system of wh ich he is a member. Furthermore, it is not clear how it i s possi b l e for the therapist to effect changes through conditioni ng when i n actual fact the technique uti l i zed by the therapist constitutes only a sma l l frac­ tion of the total environ mental sti m u l ation to which the patient is exposed. Li ke the medica! model, "behavior modifi cation" tends to i solate the symp­ tom from the context in wh ich it occ u rs. Thi s occurs even in carefu l ly for­ m u l ated statements such as the fol lowi ng of U l l mann and Krasner ( 1 965). I n their statement, they are very carefu l to relate maladaptive behavior to the soc i a l context: Maladaptive behaviors are l earned behaviors, and the development and maintena nce of a m a ladaptive behavior is no d ifferent from the development a n d mai ntenance of any other behavi or. There i s n o d i sconti n u ity between des i rable and u ndes i rable modes of adj ustme n t or between "hea l thy" or "sick" behavior. The f i rst major I m p l i cation of t h i s v iew is the question of how a be­ havior is to be identified as des i rable or u n desi rable, adaptive or m a ladaptive. The genera l answer we propose is that because there are n o d isease entities i nvolved in the majority of s u bjects d isplaying maladaptive behav ior, the des ignation of a behavior as pathological or not is dependent upon the i n d iv i d u al 's soci ety. 20)

To th i s poi nt, the i r form u l ation concern i ng '1maladaptive behavior" ex­ act l y para l l e l s the defi n ition of d eviant behav i o r presented here. They go on to further spec ify the mea n i ng of mal adaptive behavior in terms of ro les and role rei nforcement. Specifica l ly, w h i l e there are n o si ngle behaviors that wou l d be said to be adaptive in a l l c ul t u res, there a re i n a l l cu ltures defi n ite expectations or roles for fu nctio n i n g a d u lts i n terms of fam i l i a l a n d soc i a l responsi b i l i ty. Along with rol e enactments, there a re a fu l l range of expected potentia l rei nforcements. The person whose behavior is m a ladaptive does not fu l l y l ive up to the expec­ tations for one i n h i s role, does not respond to a l l the sti m u l i actua l ly present, and does not obta i n typical o r m a xi m u m forms of rei nforcement ava i lable to one of h i s status . . . . Maladaptive behavior is behavior that is considered i nappropri ate those key people In a person's l i fe who control reinforcers. (p. 2 0)

Individual and Social Systems in Deviance

25

Restated i n sociological terms, the i r form u l ation i s that dev i a nce i s the violation of social norms and leads to negative social sanctions. Aga i n, the para l lel between the psycho l ogica l a nd the soci ologica l formu l ation is qu ite close. Th i s formu l ation of maladaptive behavior in terms of role expectations and rei n forcement i s potenti a l l y a powerful psycho logical too l, since i t tends to bri ng in the mech a n i sms of social contro l and prov ides a strong l i nk, there­ fore, between i nd ividual and social system models of behavior. To mai nta i n t h i s l i n k, however, i t i s necessary t o remember that t h e class ification of be­ h avior as maladaptive is made relat ive to the sta ndards of some particu lar so­ ciety and is not an a bsol ute j udgment. (The same reason in g is app l i cable, of course, to the concept of devia nce. ) I t a ppears to be very d ifficu l t to mai nta i n a rel ativistic stance wh en t h e i n d ividual system models are used, particularly when t h e framework i s tr·ans­ m i tted to students. An i nstance of th i s d ifficu l ty i s represented by the i n ter­ personal psych i atry of Harry Stack S u l l ivan and h is students. Although S u l l ivan sought to take psych i atric symptoms out of the patient by defi n i ng them as d i sorders of i nterpersonal relations h i ps, h i s students put them back in by defin i ng menta l i l l ness as a deficiency i n the capacity for i nterpersonal rel a­ t io n s . Th i s i nd i v i d ua l i zation of soc i a l system concepts can be seen i n the U l l mann and Krasner form u l ation, when they define one criterion of mal­ adaptive behavior as not respo n d i ng to " a l l the sti m u l i actua l l y p resent." S i nce the response to sti m u l i of anyone in any ro le i s highly selective, i t wou ld seem that the defi n ition at th i s point h ad reverted to the absol ute def i n i tion of dev iance in terms of i nd ividual pathology. One function of a social system model of mental d isorder is to provide a framework for research that fac i l i ­ tates a n approach t o mental d i sorder that i s free o f t h e q uestionable as­ sumptions of i nherent pathology in psych i atric symptoms. Of the form u l ations of anthropologists, the one that most nearly para l lels the model descri bed here i s the b iocu ltura l model of Anthony F. C. Wal l ace ( 1 9 6 1 ). G iving somewhat more emphasis to organic sources of rule-breaki ng, Wal l ace pos i ts that the i n itial cause of mental i l l ness is physiologica l , but that the cu ltural "mazeways" (cognitive maps) profoundly shape the course of i l l­ ness. I n some deta i l, he notes how the "theories" of i l l ness of the sick i nd i ­ vidual, h i s fam i l y and associates, and the "professionals" i mp i nge on i l l ness as a behavior system. The ch ief components of a "theory" of i l l ness are to be: 1.

2.

The specific states ( norma l cy, u pset, psychosis, i n treatment, a nd i n ­ novative personal i ty). The transfer mech a n i sm s that exp l a i n (to the satisfaction of the member of the society) how the sick person moves from one state to another.

Ind ividual a n d Soc i a l Systems i n Deviance

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3.

The program of i l l ness and recovery that i s descri bed by the whole syste m .

Wal l ace gives an extended analysis o f o ne particular syndrome, the Eskimo pibloktoq, an acute excitement sometimes known as Arctic hysteria. Accord­ i ng to h i s theory, pibloktoq has a p hys iological base i n calcium deficiency

(hypocalcem i a) but i s shaped by the culture-bound i n terpretations made by the sick persons and those who deal with h i m . Fol l owi ng Wal l ace's model, Fogelson ( 1 965) presents a deta i led analysis of windigo, a syndrome of com­ p u l s ive can n i ba l i s m reported among Northern Algonkia n-spea k i ng I n d ians, which emphasizes c u l tu re-bou n d i n terpretations of rule-breaki ng behavi or. The relations hi p between Wa l lace's model and the model developed here w i l l be d i scussed l ater (Chapter 1 0). The purpose of the present d i scussion i s to lead to, in the next two chap­ ters, a set of n i ne propos itions that make up basi c assu mptions for a soc i a l system model of menta l d isorder. Th i s set i s largely derived from t h e work of Wal lace and Fogel son, a l l but two of the propositions (Propos itions 4 and 5 ) being suggested, with vary in g degrees o f expl ic itness, i n the c i ted references. By stating these propositions expl i c itly, this theory attempts to fac i l i tate testi ng of bas i c assu m ptions, a l l of w hich are empiri cal ly u nverified or only partly veri fied. By stating these assu mptions in terms of standard sociological con­ cepts, the relevance to studies of mental d i sorder of fi n d i ngs from d iverse areas of soc i a l science, such as race rel ations and prestige suggestion, are shown . Th i s theory a l so del i neates th ree problems that are cruci a l for a sociolog­ ical theory of menta l d i sorder: What are the cond itions i n a culture u nder which diverse k i nds of rule-brea k i ng become stable and u n iform? To what extent, i n di fferent phases of careers of mental patients, are symptoms of mental i l l n ess the res u l t of conformin g behavior? Is there a general set of conti ngencies that lead to the defi n ition of deviant behavior as a man ifesta­ tion of mental i l l ness? Fin al ly, thi s d iscussion attempts to formu l ate special conceptua l tool s that are d i rectly l i n ked to sociological theory to deal with these problems. The soc i a l i n stitution of i nsanity, res i d u a l rule-breaki ng, de­ viance, the soci al ro le of the mental ly i l l, and the b ifurcation of the societal reaction i nto the a l ternative reactions of normal i zation and labe l i ng are ex­ amples of such conceptua l tool s. These conceptua l tool s are uti l ized t o construct a theory o f mental d i sor­ der in which psychiatric symptoms are considered to be l abeled violations of soc i a l norms and stable "menta l i l l ness" i s cons idered to be a soc i a l ro le. The val id ity of th i s theory depends u pon verification of the n i ne propositions l i sted in futu re stud ies and should therefore be appl ied with caution and with apprec iation for i ts l i m itations. One such l i m itation i s that the theory attempts to accou nt for a m uch narrower c lass of p henomena than is usua l l y found

Individual and Social

in Deviance

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u nder t h e rubric o f menta l disorder; the discussion that fol l ows w i l l b e fo­ c u sed excl u s ively on stable or recurring mental d i sorder and does not exp l a i n t h e causes o f si ngle e p i sodes. A second major l i m i tation i s that t h e theory p robably d istorts the phenomena u nder d i scussion. J u st as the i nd ividual sys­ tem models u nderstress social processes, the model presented here probably exaggerates their importance. The social system model "holds constant" i n­ d ividual differences i n order to articulate the relationship between soci ety and mental d isorder. Ulti mately, a framework that encompassed both i ndi­ vidual a n d social systems and d istorted the contribution of neither wou l d be des i rable. G iven the present state of formulations in th is area, this framework may prove useful by p rov i d i ng an expl icit contrast to the more conventional med ical and psychological approaches and thus assist in the formul ation of socia l l y oriented studies of mental d isorder. It shou ld be made clear a t thi s point that the purpose of t h i s theory i s not to reject psych i atric and psycholog ical formu l ations i n thei r tota l i ty. It is ob­ vious that such formu l ations have served and w i l l contin u e to serve usefu l functions i n theory and practice concern i ng mental i l l ness. The author's p u r­ pose, rather, i s to develop a model that wi l l complement the i nd iv i d u a l sys­ tem models by prov i d i n g a complete and exp l icit contrast. A lthough the i n­ d ividual system models of mental d i sorder have led to gai n s i n research and treatme n t, they have a l so systematica l l y obscured some aspects of the prob­ lem. The soc i a l system model, l i ke the psychological model, h i g h l i gh ts some aspects of the p roblem and obscures others. It does, however, a l l ow a fresh look at the field, s i nce the problems it clarifies a re apt to be those that are most obsc u re when viewed from the psychiatric or med ical point of view. The case for the use of l i m i ted a n alytic models was clearly stated by Max Weber ( 1 949), for a n a lysis that he called "on e-si ded": The j ustification of the one sided ana l y s i s of c u l tu ra l rea l it y from specific "poi nts of view" . . . emerges p u re l y as a tec h n i ca l expedient from the fact that t ra in i ng in the observation of the effects of qual itatively s i m i lar categories of causes and the repeated u t i l ization of the same scheme of concepts and hy potheses offers a l l the advantages of the d ivision of labor. I t is free of the charge of arbitrariness to the extent that it is successful i n prod u c i ng i n s i ghts i n to i n ter­ connectio n s which have been shown to be val ua b l e i n the causal explanat i o n o f concrete h i storical events. (p. 7 1 ; quoted b y Mecha n i c 1 96 3 , p . 1 6 7)

It can be a rgued that in addition to the adva ntages of the d ivis ion of sci­ entific l abor as suggested by Weber, there is yet another advantage to one­ sided analysis. I n the nature of scientific i nvestigation, a central goal i s the deve lopment of the "crucial experiment/' a study whose resu l ts a l low for the deci sive comparison of two oppos i n g theories, such that one is upheld and the other rejected. I m p l i c i t in the goal of the crucial experi ment i s the con­ ception of science as an adversarial process in which scientific progress arises

28

Individual and Soc i a l Systems i n Deviance

out of the confrontation of exp l icitly confl icti ng theories. In h i s formu l ation of the h i story of cha nge in the natural sciences, Kuh n ( 1 962) con si ders a l l scientific progress a s the confl ict between "competing parad igms" ( i .e., op­ posi ng theories). W h i tehead has stated th i s view very c l early: "A c l ass of doctri nes is not a disaster-it is an opportu n i ty. . . . In formal logic, a con­ tradiction is the signal of a defeat; but in the evo l ution of rea l know ledge it marks the fi rst step in progress towards a victory" (pp. 2 66-2 67). One road of progress i n science i s t he i ntentional form u l ation o f m utually i ncompatible models, each i ncomplete and each expl icat i ng o n l y a portion of the area u nder i nvestigation. The advance of science, as in the theory of adversarial procedures i n law, rests on the d i a lectical process that occurs when i ncommensurate positions are p laced in confl i ct. In the present d i s­ cussion of mental i l l ness, the soc i a l system model i s proposed not as an end in itself but as the antithesis to the i nd ividual system model . By a l lowing for expl i cit consideration of these antithetica l models, the way may be cl eared for a synthesis, a model that has the advantages of both the i nd ividual and the soc i a l system model s but the d isadvantages of neither.

II TH EORY

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3 Social Control as a System

Soci a l scientists look at devian ce in a somewhat d ifferent way from other members of the society. I n order to understand devi an ce objectively (the sense in which I use th i s term w i l l be defined shortly), they a rgue, one must fi rst understand the more general p henomena of soc i a l contro l , the processes that gen erate confor m i ty i n h u ma n groups. Thi s chapter i ntroduces the the­ ory of soc i a l control and s hows how it appl ies to nondev i a n t areas such as c loth i ng and appearan ce, l anguage, fac i a l expressions, fee l i ng, and thought. S ubsequent chapters demonstrate how th i s theory may be appl ied to the phe­ nomenon of mental i l lness. Rather than s ta rt the d i scussion of soc i a l control abstractly, 1 i nd icate some e l ements of soci a l control i n a concrete area, that of c l oth i ng and appear­ ance. What deter m i nes the way people dress? In partic u lar, why i s t here so much u niformi ty in dress within a given soc ia l group? We feel that we u nder­ stand why sold iers wear u n iforms, but why do corporation executives, soror­ ity women, and co l lege p rofessors, for example? Perhaps one cou ld explore h i s or her own choice of c lot hing. What determ i nes one's style of dress or the choice of i tems in one's wardrobe? Th i s may not be a n easy question to an­ swer. I f that is the case, try reviewing the process that went i nto the choice of each particular garment. One may say, " I don't care what other people th i n k, I dress to please myself." Even if it were true l itera l l y that one d resses only to p lease oneself, it is p robably n ot true that the o p i nions of others h ave 31

32

Social Control as a System

no i m pact at a l l . Some person 's d ress expresses the message: "I don't care what you thi nk." Dressing to express th i s message betrays a form of soc i a l i n­ fluence, if only a negative one. One may extend the expl oration of the i nflu­ ences on one's appearance by review i ng how the sign i ficant people in one's l ife view you r appearance. Such an expl oration should revea l a great deal, not only about oneself but a l so about the process of social control as it ap­ plies to oneself. The soc i a l control of cloth i ng has been evoked succ i nctly by Quentin Bel l ( 1 967): There i s . . . a whole system of mora l i ty attached to clothes and more espec i a l l y to fashion, a system different from and frequently a t va ria nce w ith that con tained i n our laws and our rel igion. To go to the theatre with five days' beard, to attend a ba l l in fau ltless even ing dress . . . but w ith you r braces outside, i n stead of within your wh ite waistcoat, to scatter i n k on you r spats, to reverse your tie, these thi ngs are not i ncompatible with moral or theological teachi ng, the law takes no cogn izance of such acts. Nevertheless such behavior w i l l excite the strongest censure in "good soc iety." . . . [ l ] t is not however sheer l u natic eccentricity such as the absence of trousers or a wig worn back to front which excites the strongest censure; far worse a re those subtler forms of i ncorrect attire: the "wrong" tie, the "bad" hat, the "loud" skirt, the "cheap" scent, or the flamboyant checks of the overdressed vu lgari an. Here the censure excited is a l most exactly comparable t o that occasioned b y d i shonorable cond uct. (p. 1 8)

Although some of the terms are B ritish, the senti ments apply equ a l ly wel l to American soci ety. I n th i s excerpt, Bel l makes an i mportant poi nt: noncon­ formity to com m u n i ty standards concern i ng approp riate dress can exc i te a very strong negative response from others. F u rthermore, B e l l notes, the com m u n ity standards concern i ng cloth i ng are not legal standards or re l igious standards. They may have no forma l status at a l l . They seem to be u nwritten or even, i n some cases, u nstated r u les. Yet i n s p i te of the i r i nformal status, they wou l d appear to exert great i nfl uence over dress and appearance. Th i s issue w i l l b e d i scussed l ater u nder t h e top i c o f formal and i nformal norms. Bel l goes on to make a second i mportant poi n t about soc i a l control that concerns the rel ationsh i p between i ndividual and col l ective feel i ngs with re­ spect to dress: It i s not simply the j udgment of soc iety which acts upon the individua l . Our confusion when, h aving sat for two hours on the pl atform of a public meeting, we d i scover that we have been wearing odd socks, our sti l l worse confusion when we fi nd that our fl i es have been undone (even though nothing of any consequence has been revea l ed) has someth ing of the qual ity of gui lt. Indeed, I think it may frequently happen here, as in other moral s i tuations, that the of fender may be not simply the worst but i n fact the only sufferer. A rebe l l ious col l a r stud, a m i n ute hole i n a stocking may ruin an eve n i ng without ever being

33

Social Control as a Sys tem

observed by the company at large A sense of being perfectly wel l d ressed," a l ady is reported as saying to Emerson, "gives a fee l i ng of i n ward tranq u i l l ity which rel igion is powerless to bestow." (p. 1 9) .

.

.

.

"

Aga i n, Bel l makes an i mportant poi nt: The power o f soc i a l contro l i s n o t l i m­ ited to the operation of actual cen sure but i n c l u des the operation of i mag­ i ned censure . We a l l have suffered excru c i at i n g agon ies of embarrassment in s i tuations where the negative response of others to our appearance was mostl y or even enti re l y i n o u r i magi nation. Soc i a l control seldom operates so that i n d iv i d u a l s are passive rec i p ients of others' responses: each person p l ays an active role both by i magi n i ng future responses of others and by defi n­ i ng present actions of others as responses to one's own behavior. Each i nd i ­ vidual's actions both create a n d are created b y social contro l . I w i l l return to th is i dea shortly in the d iscussion of the part that self-control p lays i n soc i a l contro l . I n l ight of th i s d i scussion, a prel i m i nary answer now c a n b e given t o the q uesti on concern i n g the u niform i ty in cloth i ng that we see around us. Soc i a l control plays an i m portant part i n generati ng u niformity of dress a n d appear­ a nce. Soc i a l control i nvo lves the reward i ng of conform i ty to shared expec­ tations and the p u n i s h ment of nonconform i ty. Cloth i ng that conforms to the group standards of dress is rewarded with pra i se and adm i ration. If it does not conform, it is l ikel y to generate c ritic i s m or d isapprova l . The theory of soc i a l control i s the major i nterpretive model i n social sci­ ence. I t i s for th i s reason that soc i a l scientists see deviance as a type of non­ conformity and seek to u n derstan d dev i an ce in terms of the operation of soc i a l control . Th i s approach to deviance is d isti nctive to soc i a l science, sep­ arati ng it both from the view of l aypersons, on the one hand, and from the experts on devi ance l i ke psych i atri sts and pol ice, on the other. The soc i a l science approach to deviance is d i sti nctive i n th ree major ways. Fi rst, both l aypersons a n d profess ionals who deal with deviants usual l y see deviance as mostly an i nd ividual matter; that i s, they take an i nd ividual per­ spective toward deviance. What was it in the character and background of the deviant that caused h i m to become deviant? How can her deviance be stopped? Social scientists do not rule out these q uestions. But thei r framework i s broader i n that it deal s both with the i nd ividual deviant and with soci eties' response. The i ndividual perspective and the soc i a l control perspective are a l ternative ways of u nderstan d ing devi ance. A n example i l l ustrates how the soc i a l control perspective is broader than the i nd i v i d u a l perspective. At a conference on c h i l d deve lopment, there was a di scussion of the d isruptive behavior of two "hyperactive" c h i ldren i n a c lass of 30 fifth-graders. The part i c i pants were foc u s i n g o n the pos s i b l e causes o f t h e hyperactivity i n t h e backgrounds o f t h e c h i l d ren and t h e tactics that the teacher m i ght use in managi ng the i r hyperactivity, i nc l u d i ng referral

34

Social Control as a System

to a phys ician who m ight prescribe tranqu i l i z i ng d rugs. However, I had re­ membered that i n i n it i a l l y descr i b i ng the s i tuation, the observer who had i ntroduced the case had said that the teacher spoke in a monotone and was d u l l . I s uggested that we m ight d i scuss a q uestion alternative to the one on the tab le: what was wrong with the other 28 ch i ldren that they a l so were not d isruptive but tol erated d u l l teach i ng? A lthough not a l l of the participants ac­ cepted the i dea, it d i d lead to a restructu r i ng of the d i scussion to i nc l ude more of the larger context i n which " hyperactivi ty" was taki n g p l ace. There are two d i sti nctive ways of conceptua l i z i ng the sources of behav ior: in the person or in the s i tuation. Why don't my c h i ldren do their homework? Perhaps becau se they are lazy. Th i s answer p uts the sou rce of behavior in the ch i l dren and ignores the context. An a l ternative answer wou ld be becau se the homework i s too d iffi c u l t or too easy: they are not motivated by the task or the teacher. Th i s answer p uts the sou rce of behavior in the context and i g­ nores the ch i ldren . N eed l ess to say, any thoughtful analysis should a l l ow for an exa m i nation of both the i n d ividuals and the context. Often the i nd ividual perspective on the sou rces of behav i or i s a somewhat d i sg u i sed aspect of the naive societal reaction: ignore the context, p lace the cause for devi ance i n negative traits i ns i de the ru le-breakers, and p u n i s h them . Dewey put the matter succi nctly: "G ive a dog a bad name and hang it." There i s a second major way in which the soc i a l science concept of de­ viance is d i sti nctive. The concept of deviance i tself is used in a d ispassi onate way, stri pped of the opprobri u m the word ord i nari l y carries. It mea ns a vio­ lation of soci al norms that usua l l y bri ngs stigma and a strong negative reac­ tion from others. Deviance is the violation of those ru les that are felt to be worthy of h igh respect. Not a l l rule-breaking excites a negative reaction. I n d ifferent t i mes a n d p laces, the breaking of rules may b e seen a s i n novative, creative, com ical, or not worthy of notice. But when i m portant emotional l y weighted norms are broken, such a s those uphold i ng loyalty to one's country, strong fee l i ngs of outrage are usua l l y mob i l i zed. The violation of such norms i s deviance in the soc iological sense. The sociologist, however, seeks to apply the term only in a rel ative sense: in a certai n tribe, looki ng d i rectly at the emperor's face i s a deviant act-it causes outrage i n the members of the tribe but not to the sociologist as an outsider. When the sociological concept of deviance is appl ied to one's own society, it req u i res an attitude of a l ienation, u s i n g the term as if it d i d not carry opprob r i u m to us, the users, but o n l y to the other u n-self-conscious members of the society. The fi rst lesson i n t h i s d i scussion is that sociological analysis can be a l i enating. It req u i res that the ana lyst be stationed outside of h i s/her own society. AI ienation i s the sense that e lements of one's own I ife are mea n i ngless. Churchgoers someti mes feel they are merely goi ng through the motions of rel igion wi thout any deepl y fel t conviction. Many students have s i m i lar re­ actions to the i r school i ng, at least at t i mes. At the opposite po le is the feel i ng

Social Control as a System

35

of i ntegration, o f a powerfu l b o n d between one's i n ner and outward beh avior. (An exercise wou l d be to reca l l experiences i n one's own l ife of a l ienation and of i ntegration.) Stripping the word deviant of its heavy load of negative emotions may seem easy at fi rst. When one real izes that it usual ly has extremely strong emotional connotations, then one can u se the word in its neutra l , soci o l ogical sense if one chooses. Actua l ly, the emotional colori ng i s so strong and so complex that the strip p i ng operation and the d ispassionate use of the word i s a di ffi­ c u l t maneuver. We have a l l been soc i a l i zed to feel extremely strong emotions toward deviance a n d deviants, profound reactions of resentment, fear, and embarrassment. These fee l ings usual l y cannot be comp l etel y contro l l ed by the desi re to be a n a l ytic and objective. The soc io logist's i ntent to be d ispas­ sionate toward deviance exists i n strong tension with h i s/her i nc l i nation to feel the negative emotions of h i s/her own tribe. Nevertheless, the soc io l ogi ­ cal sense of dev iance i s sti l l q u i te d i fferent from the o rd i n ary sense o f t h e i dea, emotiona l l y, s i n ce th e tension between neutra l i ty and emotional com­ m itment itself is d i fferentiating. The ord i nary member of the tribe feel s l ittle or no tension i n t h i s respect: h i s/her condemnation of devi ance is whol e­ hearted and u n-self-conscious. The senti ment behi nd "Lock them u p i n j a i l a n d throw away the key" i s preval ent, even i n those who wou l d not openl y endorse such a statement. There i s a thi rd way i n which the soci o logi cal use of the term deviance is d i fferent from the conventional usage. The sociologica l concept of devi ance is embedded in a whole set of ideas about the larger system of which de­ via nce is one part. Correspond i ng to each of these i deas is a set of terms, or nomenclature, for the various parts of the system . We h ave a l ready used one of these other terms in the d i scussion, the concept of a soc i a l norm. Deviance is a n aspect of a l arger system that is composed of shared expectations, or norms, on the one h a nd, and sanctions (rewards and p u n i s hments), on the other. Systems of soc i a l control exert pressu re for conform i ty to soc i a l norms through the operations of sanctions: conformity to shared expectations is re­ warded, a n d n onconformity i s p u ni shed. S i nce the i dea of soc i a l control provi des t h i s book with i ts principal focus, in the d i scussion that fol lows, I provi de many examples of the operation of soc i a l contro l . Before doing so, h owever, I wou l d l i ke to d i scuss briefly two q uestions that the reader m ay have i n encountering this a rgument: What i s the p urpose of th i s k i n d of analysis? The i deas proposed here a re certa i n l y awkward, and you say they m ay b e a l ienating. Why i sn't i t possi b l e t o rel y on t h e experts i n our soc i ety for approaches to devi ance? Professionals su ch as pol i ce a n d cri m inologists for cri me a n d psyc hiatrists and c l i ni ca l psy­ chologists for mental d isorder, drug u se, and sexual dev ia nce are in d i rect contact with the very deviants who a re the su bj ects of th i s book. Their expe­ rience should j ustify their opi n ions. My answer to these q uestions i s in two parts. The first part i s that one

36

Social Control a s a System

should not d i scard the findi ngs and i nsights that are ava i lable i n pol i ce sci­ ence, cri m i nology, psyc hiatry, and c l i n ical psychology. Th i s k nowl edge, as suggested in the question, i s based on i nti mate and deta i led knowledge of deviants and i s therefore clearly of great va l ue. H owever, and th i s i s a big however, I wou l d a l so argue that a l though it i s val uable, i t i s not enough by i tself. There i s a n i mportant b i as i n the col lec­ tive wi sdom of the professiona l s who regularly deal with devi ants. In some i mportant ways, these professionals are part of the system of social control that is described here. They are not entirely detached i nvestigators of the process of devi ance, s i n ce they themselves must deal with deviants in ways that are acceptabl e to the society. A pol i ceman, warden, or c l i n ical psych i a­ trist or psychologist who merely objectively stu dies cl ients wou ld not l ast long in the j ob, s i nce it cal l s, at least in part, for the enforcing of the appro­ pri ate soc ial norms. The professionals who deal with devia nce, because they are part of the system of soc i a l control, usual ly have a perspective that i s, at least in part, congruent with the basic perspective of the particu l ar society they represent. Most prison wardens or psyc h i atrists are not compl etely d is­ passionate about the cri mes of their prisoners; they tend to see them, at least in part, as the society does, as abhorrent. The social control framework offers a more detached and therefore, one hopes, a more objective perspective for exam i n i ng devi a nce and the control of deviance. Th i s framework can be app l ied to deviance i n any society, in­ c l u d i ng the society of the analyst. As has a l ready been mentioned, the d is­ passionate analysi s of deviance in one's own society i nvolves the analyst i n confl ict because of the very bas i c negative bel i efs and fee l i ngs shared by a l l of the members of the society, i n c l u d i ng the soc i a l scientist. B u t confl ict m ay heighten awareness. Th i s heighten i ng of awareness may be uncomfortable for the anal yst but i t a l so i ncreases the objectivity and i n sightfu l ness of h i s/her analysis. I now return to the concept of a system of soc i a l contro l . As i nd icated, t h i s system i s com posed o f a very large set o f norms, on t h e o n e hand, and a set of sanctions, of p u n i s h ments and rewards, which enforce the norms, on the other. I beg i n the d i scussion with a description of soc i a l norms. The s i m p lest defin ition of a norm is a shared expectation, that is, a n expectation that i s shared b y the members o f a group. The sense i n which an expectation is shared is rather com p l i cated . Soc i a l norms can be i ncred i b l y rigid and i m pervious to change, but they can a l so change overn ight. Paradoxi ca l l y, norms can be both evanescent and u nyieldi ng. The great French soc i ologist Durkhe i m re­ ferred to them as soc i a l facts. It is i nstru ctive to compare these soc i a l facts with physical facts. There is a sense in which a social fact is enormously more du rable than the toughest physical materi a l . The desert tri bes who created the Ten Com­ mandments h ave long s i n ce van i shed; not a shard rem a i n s of the i r civi l i za-

Social Control as a System

37

tion. Yet the mora l code they developed i s very much a l ive today, part of the consciousness and behavior of those societies that have a j udea-Christian heritage. The Ten Commandments survive not merely in the B i b l e but in our very l ives and m i nds. Shared expectations of this kind are stronger than the strongest stee l, more d urable than gol d . A s I have said, normative codes c a n col l apse a n d van ish overnight. I n any c u l ture, pan i c and anarchy are un usual but not beyond poss i b i l ity. More usu­ a l l y, defin i te change occurs in a measu red or gradual way. Cha nges i n shared expectations concern i ng cloth i ng and appearance are an i m portant part of the p henomenon of fash ion. Another example is the pervasive change in lan­ guage over a much l onger t i me period. What is the nature of the process of sharing expectations such that norms can be either stronger than steel or weaker than gossamer? Furthermore, what i s the relationship of i ndividual expectations to those held by the group? I n some i n stances, i t i s clear even t o i ndividuals strongly opposed t o a norm that the norm exi sts, seem i ngly i ndependently of their own wi l l or the wi l l of any persons whom they know. As Durkheim indicated, col lective representations, or what we cal l here shared expectations, have exteriority and constra i nt. They may seem exterior to many or even most of the persons in the society where they obtain, and they are seen, therefore, as constra i n i ng on behavior: people actual l y feel pressure to conform. Durkhei m ( [ 1 895] 1 93 8) sees norms as so powerfu l that he gives them a l ife of their own apart from the people who create them as "parti a l l y autonomous rea l ities, with their own way of l i fe." Durkheim does not actua l l y answer the q uestion ra ised here about the nature of the process involved i n the creation and mai ntenance of shared ex­ pectations; he merely suggests that it occurs: "Co l lective representations are exterior to i nd ividual m i nds . . . . They do not derive from them as such, but from the association of m i nds, which i s a very d ifferent thi ng." H ow may one describe the deta i l s of the "the assoc iation of m i nds" that D u rkheim refers to in a way that makes the exteriority and constra i n t of norms plausible? Th i s i s a crucial q uestion for the understand i ng of social contro l . An answer h a s been suggested b y t h e economist Thomas Sche l l in g ( 1 963). It i s i n structive to repeat an example he has given of the creation of a shared expectation, i n this case, the u nderstanding between the confl icting parties that the Ya l u River was to be the bou ndary of the Korean War: If the Ya lu River is to be viewed as a l i m it i n the Korean War that was rec ogn i zed on both si des, its force and authority is to be analyzed not in terms of the joint u n i lateral recognition of it by both sides of the confli ct not as some­ th i ng that we and the Chi nese recognized u n i l atera l l y and s i m u ltaneously but as something that we "mutually recognized." It was not j ust that we recogn i zed it and they recogn i zed it, but that we recognized that they recogn i zed it, they recognized that we recogn i zed it, we recognized that they recogn i zed that we recogn i zed it, and so on. It was a shared expectation. To that extent, it was a

38

Social Control as a System somewhat undeniable expectation. If it commands our attention, then we ex pect it to be observed and we expect the C h i nese to expect us to observe it. We can not u n i latera l l y detach our expectations from it. In that sense l i mits and precedents a n d trad itions of t h i s k i n d have an authority that i s not exactl y granted to them vol u ntarily b y t h e partici pants i n a conflict. They acq u i re mag­ netism or focal power of thei r own.

In th i s example, Schel l i ng ( 1 963) gives what I consider to be an extremely precise defi n i tion of a social norm . The people who come to share an ex­ pectation need not be in actual contact or consider themselves a gro u p. I n this case, the peop le are a t war with each other. B u t they are sensitive to each other's gestures, so that they " mutu a l l y recogn ize" that they share an expec­ tation. The sharing of the expectation is very deep in that it is not j ust that the parties a l l hold the expectation i ndependently, but that each recognizes that the other holds it, and each recog n i zes that the other recogn i zes that they hold i t, and so on. The parties are not merely in agreement about the Ya l u R iver, they are co-oriented: " I know that you know that I know that i f the U n ited States forces go past the river, the C h i nese Army wi l l i n tervene." An­ other example: "I expect that others wi l l not touch me i nti mately i n pu bl ic; I assume that most others share this expectation; I assume that most others assume that I s h are t hi s expectati on," etc . A shared expectation exi sts if there is an i nfin i te series of rec i p rocat i ng attributions between the members of the group. As i n my defi n i tion, Schel l i ng ( 1 963) al lows for i n defi n itely h igh orders of reciprocating attri bution. Th i s a l l owance evokes Durkheim's exteriority and constra i n t i n i ts final sentences: In that sense l i m its and precedents and trad itions of th i s k i n d have a n author ity that i s not exactly granted to them vol u ntari ly by the partic i pants i n a con fl ict. They acq u i re magnetism or focal power of their own.

The s hared expectation is felt as a powerfu l exterior constraint because each i ndividual agrees, recognizes that h i s neighbors agree, that they each recog­ n ize that he agrees, that he recogn izes they recogn ize, and so on i ndefi n itely. Although he agrees (or d isagrees) with the senti ment, it is a l so someth in g beyond h i s power t o change, or even completely explore. The potentially end­ less m i rror reflections of each of the others' recognitions is felt as somet h i ng utterly fi nal. From this formu l ation it fol lows that each actor feel s the presence of expectation with a sense of exteriority and constra i n t, even if he, as an i n­ dividual, is h i mself wholeheartedly dedicated or opposed to the expectation. To each member of the soci ety, therefore, norms appear to have both an i n ner rea l ity, a sense of moral obl igation and rectitude, and an outer rea l ity, the sen se that others are deeply and i rrevocably i n volved i n the same moral world as oneself.

Social Control as a System

39

The i nd ividual's sense o f moral coercion from others i s complexly deter­ m i ned, because it is in part an assumption, but it i s a l so i n part based on re­ a l i ty. One can not help bei ng aware that others are not i ndi fferent to norma­ tive a spects of behavior. Even strangers, when in each other's presence, make subtle b ut forcefu l moral claims on each other. The temporary passengers i n an elevator i n h ib i t each other's behavior, even t o t h e d i rection o f glance. Most people feel compel led to look at the floor or elevator doors. These i n h ib itions arise becau se of actua l o r expected responses of others to one's behavior, as wel l as o ne's own sense of moral ity. To p u t it i n a s l i ghtly d ifferent way, the process of soc i a l control i nvolves both control by others and self-contro l . Self-control operates i n two related b u t d i fferen t ways . Fi rst, the i nd ividual can i magi ne a whole world of re­ sponse that may never occ u r. A fema le col l ege student, cons idering whether to l ive with a male friend or not, may sudde n l y see the i ssue as her mother may see it-"What wou l d mother t h i nk?"-and be g ui ded by her i m pression of her mother's j udgment. S i m i larly, before sta n d i ng u p in front of the class and giving a n answer to a q uestion, a student may cons i der h is a n swer not only from the professor's poi nt of v i ew but a l so from that of the class. In some i nstances, the student refrai ns from speaking, hav i n g i magi ned how h i s an­ swer m ight seem to one or both of these parties. Second, even rea l actions of others must be i nterpreted by the i nd ividual as to whether they are responses to the i nd ivid ua l's acts, that is, whether they are sanctions. As the student gives an answer in class, he notices that the pro­ fessor is frow n i ng. The student m ust decide if the professor's frown is a re­ sponse to the student's a nswer. The student remembers that the professor was frow n i ng before the q uestion was asked and decides that the frown i s not a response t o the a nswer. The student's i nterpretation i s verified when the professor prai ses the answer. In the process of soc ia l control, sanctions are responses by others to one's behavior. Soc i a l control i nvolves i magi native re­ hearsal and/or i nterpretation and i s therefore i n part a process of self-contro l . Sanctions may be defined a s responses that reward behav i or that i s seen as conformi ng to normative expectations (positive sanctions) or p u n i sh non­ conformi ng behavior (negative sanctions). That is, they are responses to con­ formity that bring p l easure to the actor and responses to nonconformi ty that bri ng pai n . The response need not be extreme a nd formal , as in the case of a long prison sentence for a major crime; i t can be subtle an d ephemeral-a frown d i rected at a speaker with a s l ight l isp. Socia l control exerts a powerful over behavior because the sanctioni ng process i s often contin uous and seemi ngly automat i c . Soc i a l control i s largel y i nforma l. I n most i nstances, i t goes on u n stated, u nseen, a n d u n acknow ledged. To be s u re, there are i mportant aspects of any system of soc i a l control that a re formal a n d exp l i c i t . The l egal system, both in its cri m i na l and civi l sections, and a l so the d i s c ip l i n a ry systems i n

40

Social Control as a System

organ i zations function i n a formal way as a part of social contro l . Laws, statutes, and codes may serve as exp l icitly stated norms, and fines, i mpris­ onment, and other d i sc i p l i nary p rocedu res may serve as sanctions. B u t the overlap between these formal systems and the larger system of social control in which they play a part is far from complete. In the f i rst p lace, the total system of social control in a society is vastly larger than a l l of the formal systems taken together. I n any given society, the total n um ber of laws and codes may be coun ted in the tens of thousands. The n umber of formal sanctions is usually extremely sma l l , in the h u ndreds, per­ haps. As suggested in the d i scussion of the areas of control, in which I con­ sider, as examples, d iverse areas such as clot h i ng, language, faci a l expression, thought, and fee l i ng, the tac it norms and sanctions may come to u ncou nted m i l l ions. In the second p l ace, the formal systems are n ot completely accurate i n­ dexes of the system of social contro l . A l l formal systems conta i n forms that a re not part of fu nctio n i ng system of control-b l ue-stocking l aws, for ex­ ample, statutes that are unenforced, dead- letter laws . The formal systems stand in rel ation to a system of soc ia l control as d i ctionaries and grammars stand to a l iv i n g la nguage: formal descr i ption and usage overlap bu t are d i st i nct entities.

AREAS OF SOC IAL CONTROL

A l iving l anguage can be considered to arise out of the action of a perva­ sive system of soc ia l control . On the one hand, shared among the speakers are l itera l l y m i l l ions of expectations concerning grammar, syntax, pronunci­ ation, i nflection, gesture, and mea n i ng. O n the other hand, a conti n uous sanctioning process i s occurri ng, in wh i ch conform i ty i s rewarded and non­ conformity p u nis hed. I n face-to-face conversation, it i s customary for the l is­ tener to reward the speaker al most conti n uously for conform i ty by looking i ntently at the spea ker, noddi ng one's head or making some other affi rmative gesture, and sm i l i ng or at l east refrai n i ng from frow n i ng. Each of these ges­ tu res i s a means of com m u n icating to the speaker: "You are doing fine. I am l i sten i ng. I understand. Please conti n ue." More abstractly, the l i stener i s con­ t i n u a l l y responding to the actions of the speaker with positive sanctions and, in the case of not frown i ng, with the absence of negative sanctions. Violation of expectations regard i n g l an guage, whether verbal or nonver­ bal , is usua l l y met with m i s understanding or i ncomprehension at best. Often violations bri ng responses of ridicule or censu re. Adu lts may censu re each other's l anguage violati ons subtly or d i plomatica l l y. Adults with chi l d ren, or c h i l d ren with c h i l d ren, are m uch less restrai ned. The world of the stutterer or the l isper i s usua l ly a n i ghtmare of embarrassment.

Areas of Social Control

41

G roup members are extraord i na rily sens i tive to even sl ight departu res from normative speech expectations. Variations of speech that are extremely s l ight, such as those due to social class or regional background, w i l l usually p roduce both real and i magi ned sanctions. Even a s l ight resi d ue of worki ng­ c l ass i nflection from B oston or New Orleans w i l l p roduce frowns of d i staste among m i dd le-class Cal ifornians. As al ready i n d i cated, cloth i ng a nd outward p hysical appearance present another lesson in social control . I n modern i nd ustrial societies, the rate of cha nge of the fash ion i n cloth i ng and appearance i s m uch more rapi d than fash ion in language. N evertheless, the system of control i s equ a l l y relentless. As i s frequently remarked, even the rebe l s aga i nst the harsh stri ctures of fash­ ion soon estab l ish the i r own system of contro l . The h i ppie rebel l i on of the 1 960s and the blue-jeaned, T-s h i rted adol escent of the 1 970s qu ickly devel­ oped codes of their own as p rec ise as the ones they rej ected . For a teenager at the time of th i s writi ng, the choice of fabric, style, and color i n buying a pair of Adidas sneakers may be a task req u i ri ng excruciating care. Social control is exercised not only over cloth i ng but a l so over most other aspects of outward appearance. H a irsty l i ng is an obvious case i n point. The length of men's hai r u sua l l y not o n l y exc i tes responses a l ong an aesthet i c d i mension but a l so i nvo lves more momentous i ssues very qu ickly, a s it d i d both i n Cromwel l 's England a n d i n t h e 1 960s student movement, when i t had a po l i tical s ign i ficance. The amount and sty le of facial cosmetics u sua l l y has analogous moral i mp l i cations for women. I n n i neteenth-century America, for example, rouge and I i pstick were the marks of actresses and prostitutes. In most societies, fas h i on in appearance extends to the body i tself. The amount of exposu re of leg, buttocks, m idriff, and bosom is rigidly mon itored by custom . Even the shape of the body is not exempt; deformation of the body, espec i a l l y the bod ies of women, i s regu larly attempted t h rough soci al con­ trol . The i r feet have been bound and thei r l i ps and buttocks made to protrude by su rgery in prior societies. In our own society, i njections of s i l icone are used to shape, l ift, and extend the breasts and buttocks, and su rgery rej uvenates aging faces and necks. Normative body shapes are rewarded with adm i ration; non-normative shapes are p u n i s hed with criticism or neglect. The re lentlessness and pervasiveness of soc ia l control over outward forms of behavior and appearance i s eas i l y described. But soci al control does not stop with outer forms; it penetrates deeply i nto the i n ner l ife of thought and fee l i ng. I beg i n th i s d i scussion with the issue of control over fac i al expres­ sion, s i n ce fac i al expression partakes of both outer and i n ner worlds. There are many s i tuations i n w hic h fac i a l expressio n is clearly subject to soc i a l contro l . At a funeral or a t a school exa mi nation, a s m i l e may b r i n g an open rebuke j u st as a frown may receive a s i m i la r response at a cockta i l party. I n the large cities i n modern society, a norm govern i ng facial expression i n pub­ lic appears to be developi ng: it requ i res an expression si gnal ing no emotion.

42

Soc i a l Control as a System

Some of the hu mor and apprehension generated by the fi l m Invasion of the Body Sna tchers rests on th i s issue: that the blan kness of the zombies i n the San Francisco l ocale only sl ightly exaggerates the behavior that i s becom i ng the norm i n rea l l ife. The expectation that the p u b l i c faci a l expression on a metropol i tan street w i l l be an emotion less mask presu mably shows social control only over the outward express ion of fee l i ng. Often, however, social control extends to the actual fee l i ng withi n . For examp l e, in most h uman grou ps, to feel either too much or too l i ttle grief is to be subjected to negative sanctions. A person who feel s l i ttle or no grief over the death of a parent wou l d be considered a moral monster. O n the other hand, the widow who mourns too long over her dead spouse w i l l be reb u ked . She may be told that she is bei ng "morbi d." In i n­ stances such as these, i t i s not merely outward express ion that i s being con­ trol led but especi a l l y and m a i n l y i nner fee l i ng. As Arl ie Hochsc h i ld ( 1 9 79) has i nd i cated, we expend cons iderable effort doing "emotion work," that i s, strugg l i ng either to evoke a fee l i ng that our culture deems appropriate or suppressing a fee l i ng that i t deems i nappropriate. In modern societies, the bride and bri degroom are expected to feel love for each other, although such an expectation i s a comparatively recent event i n h uman h i story. In all soc i ­ eties i n h uman h i story, i t wou l d appear that social control exerts i ntense pres­ sure on mem bers to hate the i r tribal or national enem ies, especi ally in ti mes of confl i ct or war. Much the same can be said for persons defined as i nternal enem ies, such as m i norities and deviants. A s I suggest, t h e extremely strong negative fee l i ngs mobi l i zed by acts of dev i a nce, espec i a l l y moral outrage a n d i nd i gnation, a re a centra l l y i m po rtan t aspect of the soc i a l control of devi ance. Like fee l ings, thoughts and bel i efs are aspects of the i n ner l ife that seem private, yet l i ke fee l i ngs they are a l so su bj ect to the action of social contro l . Before Magel lan, anyone w h o thought that t h e Earth m ight n o t b e flat wou l d have been considered i nsane. S i m i l arly, i n t h e 1 960s a n d most o f t h e 1 970s, activists who thought that the FBI and CIA were doing what they were actu­ a l ly doi ng were considered paranoid. The thoughts and bel iefs of ch i ldren are rigorously subject to contro l . For example, when my o ldest c h i ld was about 4 years old, he went through a period of n i ghtmares about ghosts and threaten i ng a n i ma l s that wou l d wake h i m from s leep. L i ke any other u p­ standing member of the tribe, I hastened to assure h i m that the i mages he had seen in his s leep were not rea l . (One i nc ident occu rred when I was reassur­ ing h i m after he had awakened from an a n i mal d ream . He poi nted to a fold i n the bedclothes, asking what i t was. I said, "That's j u st the sheet." Only half awake, he shouted in terror: "A s heep ! A sheep! " ) At about the same ti me, he and I were i nvolved in a protracted struggle over the clean l i ness of his hands at mea l t i me . Whenever I asked him to wash his hands, he wou l d i nspect them, then show them to me:

43

Areas of Social Control

Son:

Father:

They are not d i rty, they're clea n . But they may have germs on them.

At t h i s remark, he wou l d aga i n i nspect h i s hands: Son:

Father:

I don't see a ny germs. can't see them, they re too l ittle.

You

'

After conside rable t i me, effort, a n d emotion, I s ucceeded in conv i n c i ng my you ng son that the d ream i mages he had act u a l l y seen were not rea l a n d the germs that he had never seen were. I had functioned a s a n agent of soc i a l control over h i s bel i efs about rea l ity. Yet i n m o s t soc i eties i n h u m a n h istory, the s i tuation wou l d h ave been reversed. The i mages i n the d ream wou l d h ave been considered real, man ifestations o f t h e n i ght-wanderi ng s p i rits of the dead, whereas the germs on the hands, u nseen, wou l d have been con­ s idered u n real . To a l a rge extent, the system of social control i n a society constructs real i ty for i ts members. As s hown i n Chapter 4, the social con­ struction of rea l i ty is a centra l issue in the sociological approach to menta l disorder. To review so far: A l l h u man groups have a system of social control that shapes a l l areas of experience-behavior, perception, thought, and fee l i ng. Th i s system operates to obta i n conformity: acts that meet n ormative expec­ tations are pos i t ively sanctioned, a n d acts that violate normative expectations a re negatively sanctioned. The system acts through both actual sanctio n s and t hrough those i magi ned o r assumed. I n deed, the i magi n ed responses of others to one's acts a re probably ful ly as i mportant as their real responses i n the operation of soc i a l contro l . I n becom i ng adult members of the tribe, c h i l ­ dren q u ickly learn t o forestal l p u n i sh ment and gai n reward from others b y re­ hears i n g the i r acts i n their i magi nation. I n order to i magi n e acc u rately other's responses, the ch i l d l earns probable v i ewpo ints of others i n the society, at l east i n part. I n t h i s process of soc i a l i zation, self-control becomes a crucial aspect of soc i a l contro l . Al though soc i a l control works relentlessly, both with i n a n d w ithout, t o s h ape behavior, perception, thought, a n d fee l i ng, i t s actio n s are n o t auto­ matic and i nevi table. I ndeed, i n any given s ituation, there is some u ncertai nty not only as to whether others w i l l respond with sanctions to a given act, but even as to what the re levant expectations are. In real l ife, the p rovenance of norms and sanctions i s a matter of i n terpretation and negotiation. I n most sit­ uations, the pol ice seem to bel ieve and act as if they have cons i derable d is­ c retion i n dec i d i ng whether or not a cri me has been com m i tted. Pol i ce may defi ne behavior that cou l d be seen as vandal i sm as a p rank: " Boys w i l l be boys." Furthermore, if they decide that a crime has been com m itted, they seem to bel i eve and act as if they had consid erable d i scretion to dec i de

44

Social Control as a System

whether or not to sa nction the purported offender. Relentlessly as it may seem to function when viewed abstractly, in a ny given s i tuation, the operation of soc i al control has a p robabi l i stic and i n determ i nate cha racter. Th i s i ndeter­ m inate character of social control is an essen tial feature and p rovides, there­ of fore, consi derabl e matter for del i beration for potential offenders, social control, and for schol a rs oi deviance. To be sure, one can i magine i n stances where the am biguity of the is van i sh i ng l y s ma l l . If I seek to remove the gol d from Fort Knox by stealth o r force of arms, the l i ke l i hood that my action, if detected, wou l d not be defined as a violat io n o r not sanctioned negatively may be i n fi n ites i m a l l y sma l l . rlowever, i t i s n o t i nconceivable. For example, i t i s u n l i kely, but not i m possi bl e, that my action may be defi ned as a n act of national l i beration. Needless to say, the odds at t hi s particular moment m ay be astronomically long. The poi n t i s that s ince the operation of social control i nvolves h um an beings wi th the capaci ty for i nterpreting a nd negotiat i ng, there i s always a n element o f u ncertai n ty. To put i t i n a somewhat d i fferent way, each t i me a shared conformity to expectation i s upheld by pos i tive sanctioning or non­ conformity is pun ished, the system of social control is affirmed anew. A social order i s stab le i nsofar as i t receives cont i n uous affi rmation in the l ives and actions of i ts members. At a ny moment, such affirmation may cease. When i t does, the order will change or even d isappear. I nvo lvement in a soc i a l order requ i res the cont i n u a l re-creation of that order by its members. There is an i m p l ication of the idea of the i ndeterminacy of soc ial control that the reader, in h i s or her capacity as a member of the tribe, may fi n d h a rd to accept. Crimes and other normative violations are not only relative to the moral order of a particular tribe. The mora l order i tself is not absolute and fixed but subject to pervasive a nd continuous testing, in every act, thought, and fee l i ng of i ts members. J ust as the mora l order is cont i n u a l l y c reated anew, so every deviant act is a creation, not o nly of the deviant but also those who i n terpret h i s o r her behavior as dev i a nt . Categories of are not absol ute: There i s no such t h i n g a s crime per se or, as shown in the chapter on mental i l l ness, psych iatric symptom s per se. The actions that a re categor i zed i n t h i s way a re selected by each soci ety somewhat d ifferently an d i n each concrete i n stance with i n a given soci ety are i n terpreted and negoti­ ated anew. The p h i l osopher Kant sai d : "Two thi ngs fi l l the m i nd with awe: the starry sky above and the mora l law with i n ." The process of soc i a l control, of w h ich the "the moral l aw within" i s a part, is i tself an awesome and i mprobab l e p henomenon . I ts operation i s usua l ly pervasive, relentless, a n d i nvisible, ca­ pable of stabi l i ty for m i l lenn ia, and equally capable of gradual or i n stantaneous change. O u r d iscussion now turns to the operation of social control in one parti cul ar area, the control of deviance.

The Societal Reaction to Deviance

45

T H E SOC I ETAL REACTION TO DEVIANCE

As a l ready i nd i cated, the concept of devi ance i s w i dely used in soc i a l sc ience t o mean violations of normative expectations that are l ikely t o bri ng responses of i ndi gnation and moral outrage from members of the tri be. In th i s u sage, therefore, most normative vio lations a re n o t seen a s i n sta nces of devi ance . Although belch i ng at a formal d i n ner wou l d certa i n ly be i mpol i te and wou l d e l i ci t some moral outrage i n Western societies, i t wou l d not be considered deviant behavior of the level of other violations such as m u rder, treason, or i ncest. I n some Bedo u i n societies, however, it is not o n ly pol i te but expected. How does one draw the l i ne to d i sti nguish between devi ance and other vi olations? In th i s d i scussion, I fo l low the usage that devia nce is a normative violation that may obta i n a l l th ree of the fol l owi ng responses: moral outrage or s tigma, segregation, and labeling. The possi b i l i ty that these th ree responses w i l l fol l ow a violation can be used to define deviance. In th i s d i scussion, I argue that stigma i s the s i ngle most i m portant aspect of the societal reaction to deviance, and that it is a l so the most i ntricate. The d i mensions of the other two components are straightforward . Segregation i mp l ies spec i a l procedu res for dev ia nts: prisons, asy l u ms, c r i m i n a l cou rts, comm itment hearings, drunk tanks. A l l societies have a particular status re­ served for devia nts and formal p rocedures for demot i ng offenders i nto that status and for promoting them back i nto the status of normal members of so­ c iety. We retu rn to th i s issue in the d i scussion of status l i nes. Labe l i ng, in the sense that i t i s u sed here, is one particular aspect of the process of the segregation of deviants i nto a spec ial status. By virtue of the special proced ures of segregation, the offender receives an official label (e.g., th ief, convict, sch izophren ic, mental patient, prosti tute). These labels or sta­ tus names are al so related to stigmatization, however, s i nce they always carry a heavy weight of moral condemnati on. At the core of the societal reaction to deviance is the p rocess of stigmati­ zation . Devi ance i s behavior that arouses extraord i nari ly strong col lective l oath i ng. A deviant i s that person whose n ormative violations have aroused strong emotions in the other members of the society. In the process of label­ i ng, th i s moral opprobri u m somehow becomes attached to the devi ant; he or she is stigmatized. I n order to understa nd the societal reaction, i t i s necessary to rea l i ze that the emotional reaction to deviance i s usually in excess of the appropriate re­ sponse. I call thi s excess, which may be q u ite smal l or very large, the surplus emotional response. Stigma occurs because of the surplus. H ow i s i t possi b l e to speak of a s u rp l us emotional response? There i s a d i ffic u l t j udgment i n vo l ved, because there i s a l ways a com ponent of the

46

Social Control as a System

emotional response to deviance that i s appropriate. A soc i a l order i s b u i l t u pon pred i ctable behavior. U npredictable behavior often bri ngs soc i a l trans­ actions to a standst i l l and therefore gives rise to fear and anger. Consi der one of the rules of the road, "Stay on the right side of the road." There i s noth i ng i nherently correct about the right side of the road. The left wou l d do equal l y wel l, as it does i n England. O nce chosen, however, i t becomes sacrosa nct. The soc i a l system of the h ighways does not work perfectly or even very wel l, s i n ce there are many co l l isions. Nevertheless, driv i n g on the wrong s ide of the road is a normative violation that bri ngs very strong negative emoti ons of anger and fear: "You crazy son-of-a-bitch, you're try i ng to ki l l me ! " The shared expectations of the h ighway bring some predictabi l ity to behavior and therefore a measu re of safety. Oddly enough, the repeated violation of the h ighway code, even though i t may have deadly res u l ts, is not h ig hly stigmatized . In the U n i ted States, at least, the soci etal reaction to violations of the rules of the road, rather than arousing an excess emotional response, does the opposite. There seems to be a deficit rather than a surp l us emotional response. The p u n i sh ment of traffic violations is notoriously l ight compared w ith other kinds of offenses of com­ parable harm or i nj u ry. Perhaps, l i ke hom icide in Roman law, m idd le-cl ass people are protected from offenses that they are l i kely to perpetrate. It is si g­ n ificant that there i s no vernacula r label, a short and opprobrious epithet, comparable to th i ef or whore, for the long-term traffic offender. On the other hand, there are the stigmatized offenses, such as those agai nst person or property, the ru les of rea l ity, sobriety, and sexual propriety. There is always a label, both official and vernac u lar, for these violators and for their violations. These l abels are surface man ifestation of a deep and i ntense emo­ tional response i nvolvi ng fear, anger, and/or embarrassment. Why these par­ ticular emotions? One reason for fear arousal has a l ready been i n di cated i n the discussion of the rules of the road. Normative behavior gives rise to a pre­ d ictable world in a very concrete and practical way. Adherence to conven­ tions of speech, d ress, and fac ia l expression al lows each of us to col l aborate with others with a m i n i mu m of effort and confl ict. Suppose you are wa l k i n g b y you rself i n a secl uded section of a park i n a strange c i ty. I f you meet a stranger who is b i zarrely dressed, speaks i n an odd way, and/or s hows a facial expression that seems i nappropriate to the context, you wou ld probably be frightened because you wou l d not know what to expect. On the other hand, the same stranger in the same situation, if he is conform i ng in d ress, speech, and facial expression may not be particularly fearful . Every item of dress, word, and fleeting facial expression bri ngs reassurance of pred ictab i l i ty. There i s another way i n which normative violations generate fear that i s somewhat di fferent from t h e s i m p l e issue o f t h e predictabi l ity o f spec ific ac­ tions. As al ready i nd i cated, most of the real ity of the world that is experienced by human bei ngs is soc i a l ly constructed. Wholesale violations of social norms

The Societal Reaction to Deviance

47

shatter this world. In a racist society, any pertu rbation of the color l i ne may be experienced as cataclysmic. There is a sense of shock, at l east i n itial l y, even when the vio lations are l ocal and temporary. For me, the fi rst few days of driving on the left s i de of the road i n England has a n i ghtmare qual i ty. Vi­ olations of constitutive soc ia l norms give rise to ontological fear, that is, the fear that rea l ity itself is col lapsi ng. The explanation of the emotions of anger and resentment that deviance arouses corresponds to the l i n k between u npred i ctabi l i ty and fear previously d i scussed. U npred i ctabi l i ty gives rise not only to danger but al so to frustra­ tion. It is di ffi c u l t to get through a soc ia l transaction with a person who i s breaki ng the ru les. Frustration is t h e basic context for anger and resentment, particularly where there is even a suspicion that the frustration is i ntentional. Most members of the tri be, most of the t i me, suspect that deviance is w i l led. A nger i s the result. Exp lai n i ng the function of the emotion of embarrassment that arises i n con­ nection with deviance is less obvious. Embarrassment usual l y arises in con­ texts where a person l oses face in p ub l ic. H u m i l iation is a very strong form of the same emotion. It is easy to see that the rule breaker herself wou l d be embarrassed, even if she is the o n l y one who perceives her gaffe, as suggested i n the q uotation from Bel l concern i n g i nappropriate c loth i ng. But what about the others who witness the rule violation? Why should they be embarrassed? The answer to t h i s question is not at al l obvious. One reason i s that persons who are cooperating with each other in man­ agi ng a social transaction necessarily and i nevitably i dentify with each other. Suppose I am i nvolved with another person i n l ifti ng a table. I n order to co­ ord i nate our actions, I m ust see the whole transaction not o n l y from my poi nt of view but from the other person's as wel l . Th is kind of identifi cation i s not moral and empath i c, at least not in the first i nstance. It i s simply practical. To understand the speech of another person, even if I happen to d i s l i ke that per­ son with great i ntensity, I necessari ly m ust take that person's point of view, to locate myself with respect to that person's position, to grasp the mea n i ng of the speech. Th is k i n d of process is referred to as role-taking and is thought to be the basis of i nteraction between h u man bei ngs that is disti nctively social . The idea of soci al norm as an i nfi n i te series of shared attributions predicates role-taki ng. G iven the phenomenon of role-taki ng, the basis of embarrassment over de­ viance by onlookers can be grasped. O n l ookers are embarrassed over acts of devi ance because they almost automatica l ly i dentify with other members of the tribe. Perhaps it is for this reason that most people conspi re to avoid em­ barrassi ng others, generati ng tact about tact. I t is not merely ki n dness but self­ protection. Embarrassment is extremely pai nfu l to witness: bl u sh i ng, averting the gaze, looking at the floor, wish i ng to escape the scene yet feel i ng para­ lyzed and shamed. The pai n can be d i rect for oneself or vicarious for another.

48

Social Control as a System

B u t there i s a more fundamental reason for embarrassment and shame re­ sponses i n the societal reactio n . The rules of behavior that govern soci al i n­ teraction are not o n l y exterior to us. I n our soc ial i zation, they become part of us, our second nature. They make up a substantial part of each self. For this reason, deviance i s persona l l y offensive; we fee l wou n ded and betrayed by it. The m u ltiform contracts for behavior and being that each of u s has entered i nto are th rashed by deviants. Cri m i nal deviance announces that the l egal order that we accept as part of the natu ral state of t h i ngs i s not sacrosanct. The behavior of the "menta l ly i l l," s i m i larly, annou nces that the emotional! rel ational wor l d i s a l so not i nvio lab le; i t vio lates the emotional/relational status quo. Th i s issue w i l l be considered in the next chapter, which translates the symptoms of mental d isorder i nto " residual devia nce," the breaking of taken-for-granted rules. One d i rection that t he soc i etal reaction takes i s h u m i l iated fury. Those per­ sons whose sense of self is i nsecure may react v iolently and i rration a l l y to the th reat of crime or mental d isorder. The i r mora l order has been violated, and someone must pay. Persons in the grip of h u m i l i ated fury become obsessed w i th contro l l i n g or p u n i s h i ng those are who are seen as a threat to their moral order. By projecting the entire problem onto others, rather than a l so fac i ng the i r own shame and i nsecurity, they escape from i ncreasing the i r own self­ awareness. The p a i n of shame and embarrassment i s an i mportant aspect of the emotional response to devi ance as are the emotions of anger and fear. At least a part of the emotional response to deviance is usually d isplaced onto the deviants from other areas of the i ndividua l 's l ife. Dev iants (and en­ emies and strangers, as wel l) are heirs to our ch i ld hood fears of the bogeyman, of the dark, of a l l that i s un known and menaci ng. It i s t h i s displacement of emotion that gives rise to the i ndel i b i l i ty of stigma and to many of the other pec u l iarities of the societal reactio n . I t long h a s been observed that there i s a cyc le i n t h e societal reaction to devi ance that conta i n s three p hases: q u i escence, expose, reform or repres­ sion, fo l lowed by a repetition of the cyc le (Lemert 1 95 1 , pp. 5 5-64). Pub l i c attention t o prisons a n d menta l hospita l s i s part i c u l arly marked b y th i s cycle, but it can a l so be observed in the cyc le of pol ice attention to dru n ks and vice. Th i s cyc le i s d iffi c u l t to u nderstan d on rational grounds, s i n ce reason­ able attempts to solve outstand i ng soc ia l problems wou l d be marked by a more or l ess constant level of concern and attention. When based on i rra­ tional emotions, however, responses are apt to be too l ittle or too m uch . That is, these emotions are denied u nt il some shocking event necessitates actio n . When th i s occu rs, there i s u s u a l l y an overreaction, a hysterical outburst of concern . The den i a l of emotion corresponds to the phase of q u iescence; the second phase, the expose, is the trigger for the l ast phase, the hysterical overk i l l of the phase of reform or repression. The effects of the s u rp l u s emotional response to devia nce can a l so be seen

The Societal Reaction to Deviance

49

i n another way. The i n del i b i l ity of stigma results from the surp lus, si nce it i s displaced a n d therefore q u i te i rrationa l . T h e formal structu re o f retribution or treatment never qu ite removes a l l the stigma; the ex-offender or ex-mental patient who has "served his ti me" or been "cu red" sti l l carries some of the sti gma of deviance in most cases. The i rrational component of stigma also helps explain the cyclical character of the soci etal reaction. Really effective re­ form is difficult to mobi l ize because formally designated deviants are tainted by stigma: their cause is subtly discounted i n the pol itical process. A flagrant version of this process can be seen in publi c reaction to gangland k i l l i ngs: "Let them kil l each other off." But it also appl ies, in a more s u btle way, to a l l societal responses t o devian ce . Another example o f t h e d iscounting process c a n b e seen i n some remarks once made to me by a member of the Chamber of Deputies in Italy. Th i s deputy was describ i n g s o m e of the notorious flaws i n t h e mental health sys­ tem in Italy. When I asked h i m why there were no reform b i l l s i n the cham­ ber, he said: "No one wants to defend the menta l l y i l l . I n I taly they are cal led 'pazzi . ' If I were to i n iti ate a reform law, my opponents wou l d say, that I am pazzo too" (at th i s point he makes a c i rcular mot i o n w i th h i s i n dex fi n ger pointed at h i s temple). The menta l ly i l l are so tai nted emotiona l ly that the i r tai nt may rub off o n the i r protectors. For th i s reason, it i s d iffi c u l t to mount a rational program for the management of deviance. Most programs a re marked e ither by i mp u lsive action, on the o n e hand, or by preten se, on the other, correspondi ng to the hysterical o r to the den i a l phase i n the dyn a m i c s of col lective emotion. As can be seen qu ickly from the preced i ng di scussion, some of the ideas used i n outl i n i ng the soci a l control of dev iance are vague and e l u s ive. It is easy to poi nt to the procedures and labels u sed in the segregation of formally certified deviants. But where do we find the emotional responses that have been emphasi zed i n this d i scussion? How can one tel l i f there is a surplus emotional response or a deficit? S i m i l arly in the discussion of the normative system, one can easi l y locate and l is t l aws and codes that a re part of the for­ mal syste m . B ut how can one find the u nwritten rules a n d the unstated codes? These are i mportant questions, and they a re d iffi cult to answer. I nvestiga­ tions of these i ssues are occurring at the frontier of social science and psy­ chology. A very conservative position to take would be that until there is a wea lth of agreed-upon facts about these matters, they should be left out of the recko n i ng. I take an alternative position. A l l of us act upon our u nderstand­ ing of emotional responses and unstated rules everyday. Th i s discussion w i l l appeal t o the untutored i ntu ition o f t h e reader. To b e competent i n soc i a l i n­ teraction, one m ust be an "expert" i n these matters, although one's expertise is so taken for granted that it i s hardly ever acknowledged. I bel ieve the con­ servative position on evidence and fact in social sc ience is a useful strategy for research and teach i ng, but i t i s q u i te i ncomplete. To rely completely on

Soc i a l Control as a System

50

formal, stated knowledge i n soc ia l sci ence is to make us foreigners in o u r o w n country, having only textbook knowledge o f t h e language and t h e cus­ toms, and therefore rea l l y not u ndersta n d i ng even the s i m p l est soci al trans­ action, l et a lone the more complex and subtle ones. Th i s book w i l l appeal to both scientific knowledge and to the reader's i ntuition in order to convey a soph isticated u nderstanding of deviance and soc i al control .

CONCLUSION

I n the precedi ng d i scussion, the theory of the soci al control of deviant be­ havior has been outli ned. The theory posits a system for obta i n i ng conforming behavior that i s u n ique to each particu l a r society. The pri n c i pa l components of the system are a vast set of norms that are su pported by sanctions. De­ vi ance in a particular system is those normative violations that arouse pub1 ic outrage and can resu It i n segregation and label i ng of the offenders. F i n a l l y, the procedu res for segregation and label i ng res u l t i n a status l i ne that d ivides offenders from nonoffenders. The concept of the status I i ne suggests a way of i nterpreting the cau sation and ma nagement of deviance that is a l ternative to perspectives that focus on i nd ividuals. What i s the advantage of the soc ia l control perspective? I s it anyth i ng more than a new set of spec ia l terms? One advantage has a l ready been suggested i n u s i ng speci al terms. Concepts l i ke soc ia l control, norms, and deviance help the analyst to d i sengage from the culture-bound perspective of the so­ ci ety bei ng studied. They are general terms app l i cable to any society, so that compari sons are made eas i l y. Fu rthermore, these terms help to detach the ar­ gument from the emotional val ues of a particular society, so that objectivity i s i ncreased. There i s a second advantage that has not been mentioned yet i n th i s d is­ cussion. The soci a l control perspective is much broader than the i ndividual perspective in that i t does not p rej udge in confl i cts between i nd ividual de­ vi ants and society. The i nd ividual perspective suggests two questions: What causes devi ance? and How can i t be stopped? These are i m portant questions, but they do not exhaust the ki nds of q uestions that s h o u l d be asked about deviance. There are h i storical q uestions concern i ng soci al control : Why does a particular society define as deviant a behavior that another society does not? For exam ple, the i nd ividual perspective does not exhaust the issue of mari­ j uana use in our era. Why do young people smoke marijuana, and how can i t be stopped? A more i nteresti ng q uestion is, Who opposes marij uana use, and why is t h i s opposition so strong? W hy is marijuana u se more severe l y pena l i zed than the u se o f alcohol and tranqu i l i zers? Th e soci al control per­ spective ca l l s attention to the system of norms and sanctions as wel l as to the offenders and their offenses.

Conclusion

51

One tactic i n understan d i ng deviance concerns b road c lasses of deviance. As suggested i n l ater chapters, crime is produced by crim i na ls, but it is also produced by legislatu res. If a legislature were to change the l aws govern i ng corporation violations and other "wh ite-collar'1 cri mes to crim i nal, rather than civil actions, it cou l d create thousands of crimi nals overnight. A move in the opposi te d i rection is currently happening in psych iatry: It has been agreed that homosexual i ty is not a mental i l l ness. To the extent that this new defin i ­ t i o n is accepted b y psychiatrists a n d other key societal agents, thousands of homosexuals w i l l be promoted out of thei r deviant status. The social control perspective can also be appl ied to partic u lar cases of de­ viance. Why are some offenders detected and p u n i shed and others ignored? Th is is the basic question asked by the " l abel ing" approach to deviance. Th is approach i s concerned with the conti ngencies that give rise to status demo­ tion for some offenders and not for others. It is a l so concerned with the ef­ fects of segregation, labeli ng, and stigma on "chron icity" (i .e., on the stabi lity of rule-brea k i ng behavior) . During one poi nt i n English h istory, a man con­ vi cted of theft was branded with an F (for felon) o n his forehead. Thi s action ensured a career of robbery, since a person so b randed coul d never obtai n honest employment. Th is was an extreme i n stance o f the way i n which the societal reaction to devia nce p roduced fu rther deviance. The labe l i ng ap­ proach concerns the ways in wh ich society produces deviance, sometimes i n ways that are considerably more s ubtle than brandi ng. jerome Frank ( 1 961 ) among others, has addressed this issue as it concerns mental i l l ness: ,

certai n types of d istress o r behavioral oddities By teac h i n g peo p l e to as i l l nesses rather than a s normal reactions to l i fe's stresses, harm l ess eccen­ tricities, or moral weak n esses, it may cause alarm and i ncrease the demand for psychotherapy. This may exp l a i n the c u rious fact that the use of psychotherapy tends to keep pace w i t h its ava i l a b i l ity. The greater the n u mber of treatment fa c i l i t i es and the more widely they are known, the l a rger the n u m ber of persons seeki ng t h e i r help. Psychotherapy is the o n l y form oi treatment that a t least to some extent, appears to create the i I I ness it treats. (pp. 6 7)

As is the case with most other areas of h u m a n behavior, our u nderstand­ ing of deviance is at a very elementary leve l . The social control perspective offers the opportu n ity for b roaden i ng the level of analysis and therefore of i ncreasing our awareness in a complex and confusing area of i n q u i ry.

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4 Resi d u al Deviance

One source of i mmediate embarrassment to any soci a l theory of "menta l i l l­ ness" i s that the terms used i n referri ng to these p henomena i n o u r soc i ety prejudge the i ssue. The medi ca l metaphor " menta l i l l ness" suggests a deter­ m i nate process that occ u rs w i th i n the i n d i v i d u a l : the u nfo l d i ng and devel ­ opment o f d i sease. I n order t o avoi d t h i s assumption, w e w i l l uti l i ze soc i o­ logical, rather than medi cal concepts to formu l ate the problem. Part i c u larly cruci a l to the formulation of the problem i s the idea of psyc h i atric "symp­ toms/' which is appl ied to the behavior that is taken to s ignify the existence of a n u nderlying menta l i l l ness. S i nce in the great majority of cases of men­ tal i l l ness, the exi stence of th i s u nderl y i ng i l l n ess i s u n p roved, we need to d i scuss "symptomatic" behavior in terms that do not i nvolve the assumption of i l l n ess. Two concepts seem to be s u i ted best to the task of d iscuss i n g psyc h i atric symptoms from a soci ological poi nt of view : r u le-break i n g and devi an ce. R u le-break i n g refers to behavior that i s in dea r violation of the agreed-upon rules of the group. These ru l es are u s u a l l y d i scussed by soci o l ogists as soc i a l n orms. If the symptoms of ment a l i l l ness a re t o be construed as vi olations of soc i a l norms, it is necessary to specify the type of norms i nvolved . Most norm violations do not cause the violator to be labeled as menta l ly i l l, but as i l l­ mannered, ignorant, s i nfu l , c r i m i n a l , or perhaps j ust harried, dependi ng o n the type of norm i nvolved. There are i nnu merable norms, however, over which 53

54

Residual Deviance

consensus i s so comp lete that the members of a gro u p appear to take them for granted. A host of such norms surrou nds even the s i mp lest conversatio n : a person engaged i n conversation i s expected t o toward h i s partner, rather than d i rectly away from h i m; i f h i s gaze i s toward the partner, he i s expected t o look toward the other's eyes, rather than, say, toward h i s fore­ head; to stan d at a proper conversational d i stance, neither one i nch away nor across the room, and so o n. A person who regu larly vi o lated these expecta­ tions probably wou l d not be thought to be mere l y i l l -bred, but as strange, b izarre, and fri ghten i ng, because h i s behavior viol ates the assumptive world of the group, the worl d that i s construed to be the only one that i s natural, decent, and poss i ble. The concept of dev iance u sed here w i l l fol l ow Becker's ( 1 963) u sage. He a rgues that deviance c a n be most usefu l l y considered as a qual i ty o f people's response to an act, rather than as a characteristic of the act i tself: Soci a l groups create deviance by making the ru les whose i nfraction consti tutes deviance, and by applying those r u l es to particular people and labe l i n g them as outsiders. . . [ D] ev iance i s n o t a qual ity o f t h e act the person comm i ts, but rather a of the appl i cation by others of ru les and sanct i ons to an "offender." deviant i s one to whom that label has successfu l l y been app l i ed; deviant behavior i s behavior t h a t people s o label. ( p . 9)

By this defi n ition, dev iants are not a grou p of people who have com m i t­ ted the same act, b ut a re a grou p of people who have been stigmatized as deviants. Becker argues that the d i st i nction between r ul e-brea k i ng and deviance i s necessary for scienti fic p urposes: S i nce dev iance i s, among other t h i ngs, a consequenc e of the responses of others to a person's act, students of deviance cannot assume that they are dea l i ng with a homogeneous category when they study peopl e who have been labeled deviant. That i s, they can not assume that these people have actu a l ly . . broken some rule, because the process of labe l i ng may not be i nfa l l i b l e . . . . Furthermore, they cannot assume that the category of those l abeled deviant w i l l contai n a l l those who actua l ly have broken a ru le, for many offenders may es­ cape apprehension and thus fa i l to be i nc l uded i n the pop u lation of "deviants" they study. I n sofar as the lacks homogeneity and fai ls to i nc lude a l l to find common fac t h e cases that belong i n it, o n e cannot rea�onably tors of personal ity or l i fe s ituation that w i l l account for the supposed dev iance. (p. 9)

For the p u rpose of t h i s d i scussion, we w i l l conform to Becker's separation of ru le-breaki ng and deviance. R u le-brea k i n g w i l l refer to a class of acts, vi­ olations of soci al norms, and devi ance to particular acts that have been pub­ l icly and offi c i a l l y labeled as norm violations.

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U s i n g Becker's d i sti nction, w e c a n categori ze most psych iatric symptoms as i nstances of residual rule-breaki ng or res idual deviance. The cu l tu re of the group provi des a vocabu lary of terms for categori z i ng many norm violations: c ri me, perversion, dru n kenness, and bad manners are fami l iar examples. Each of these terms is derived from the type of norm broken and, u lt imatel y, from the type of behavi o r i nvolved. After exhausting these categories, however, there i s al ways a resi d ue of the most d iverse k i nds of violations for which the c ulture provides no exp l ic it label. For example, although there i s great cu l ­ tura l variation i n what is defi ned as decent or real, each cu l ture tends t o reify i ts defin ition of decency and rea l i ty and so provi des no way of handl i ng vio­ lations of its expectations i n these areas. The typical norm govern i ng decency or rea l i ty, therefore, l itera l ly "goes w ithout say i ng," a n d its v i olation is u n ­ th i n ka b l e for most o f i ts members . For t h e conve n i ence o f the soci ety i n con stru i ng those instances of u n namable r u le-breaking that are cal l ed t o i ts attention, these violations may be l umped together i nto a residual category: w itchcraft, spirit possession, or, i n our own society, mental i l lness. I n this di s­ c u ssion, the d iverse k i nds of rule-break i ng for which our soci ety provi des no exp l ic it l abel and that therefore someti mes lead to the labe l i ng of the violator as mental l y i l l, wi l l be considered to be technically residual rule-breaking. Let us consider further some of the i m p l i cations of a defi n ition of psy­ c h i atri c "symptoms" as i n stances of residual devia nce. In Behavior in Public Places, Coffman ( 1 9 64) develops the i dea that there is a complex of soci al norms that regu l ate the way i n w hic h a person ma y behave when i n the pres­ ence, or potentia l ly i n the presence, of other persons. Coffman's d i scussion of the norms regardi n g " i nvolvements," part i c u l ar ly, i l l u strates how such psy­ chi atric symptoms as withdrawal and h a l luc i nations may be regarded as vi­ olations of residual rules. N oting that l ol l i ng and lo iterin g a re usua l l y specifica l ly pro h i bited in codes of l aw, Coffman goes on to poi nt out that there is a much more e l aborate set of norms centeri ng around the expectation that a person appearing in public should be i nvol ved or engaged i n doing someth i ng: The rule agai nst "hav i ng no purpose," or being d i sengaged, i s evi dent i n the exploitation of unta x i ng i nvolvements to rational ize or mask des i red lol l i ng a way of covering o ne's physical presence i n a s i tuation w ith a veneer of ac cepta b l e v i s i b l e activity. Thus when i nd i v i d u a l s want a "break" i n their work routin e, they may remove themselves to a p l ace where it is acceptable to smoke and there smoke in a pointed fas h i o n . Certai n m i n i m a l "recreational" activities are a l so used as covers for d i sengagement, as i n the case of "fi s h ing" off river banks where it is guaranteed that no fish w i l l d i sturb one's or "getting a tan" on the beach activity that shields reverie or sleep, although, as with hoboes' lol l i ng, a special u n iform may have to be worn, which proc l a i m s and i nstitutiona l i zes the relative i nactivity. As m ight be expected, when the context firmly provides a domi nant i nvolvement that is outside the situation, as when

56

Res i d u a l Dev i a n ce r i d i ng i n a tra i n or a i rp l a ne, then gazi n g out the w i n dow, o r reverie, or sleep­ i n g may be quite perm issible. In short, the more the sett i n g guarantees that the partic i pa n t has not withdrawn from what h e ought to be i nvol ved i n , the more l i berty i t seems he w i l l have to m a n i fest what wou l d otherw i se be considered withdrawal in the s i tuation . ( 1 964, pp. 5 8 5 9)

The rule req u i r i ng that an adult be 11i nvolved" when i n public view i s un­ stated in o u r society, yet so taken for granted that i n d ividuals a l most auto­ matical ly s h i eld their lack of i nvolvement i n soc i a l l y acceptab l e ways, as i l ­ l ustrated i n the quotation. Th us the rule of i nvolvement wou l d seem to be a residual rule. Two types of involvements that Coffman discusses are particularly relevant to a d iscussion of res idual d ev i a nce: "away" a n d "occu lt i nvol vements." "Away" is descr ibed in this manner: W h i l e outwa rd l y part i c i pati n g i n an activity w i t hi n a soc i a l situation, an i n ­ d i v i d u a l c a n a l low h i s attention to turn from what he and everyone e l s e con­ s idered the real or serious world, and give h i m se l f up for a t i m e to a play l ike world in which he a lone part i c ipates. Th i s k i n d of i n ward em igration from the gatheri n g may be cal led "away," and we find that strict reg ul at i o n s obtai n re­ gard i n g i t. Per h a ps the most i m portant k i n d of away i s that t h rough w h i ch the i nd iv i d u a l rel ives some experi ences or rehearses some fu ture ones , t h i s tak i n g t h e form o f what i s various ly cal led reverie, brown study, woo l gathering, daydream i n g or autistic t h i nk i ng. At such times the i nd i v i d u a l may demonstrate h i s absence from the c urrent s i t u a t i o n by a p reoccup ied, faraway look in h i s eyes, or by a sleep l i ke sti l l ness of h i s l i mbs, or by that spec i a l c lass of side i n­ volvements that c a n be susta i n ed i n a n utte r l y " u n conscious" abstracted man­ ner-h u m m i ng, dood l ing, d ru m m i n g the f i n gers o n a tab le, h a i r twi sti ng, nose p i ck i ng, scratch i n g. ( 1 964, pp. 69 70)

Th i s d i scussion i s relevant to the psychiatric symptoms that come under the rubric of "withdrawal," show i ng that the behavior that i s cal led with­ drawal i n itself i s not socia l l y unacceptable. A n "away" i s met with p u b l i c censure o n l y when i t occu rs i n a soc i a l ly unacceptable context. B ut t h i s i s to say that there are residual rules govern i ng the context in which "aways" may take pl ace. When an "away" violates these ru les, it is apt to be cal led "with­ d rawal" and taken as evi dence of mental i l l ness. "Occ u l t involvement" is defined as a s ubtype of "awayness": There i s a k i nd of awayness where the i nd iv i d u a l gives others the s ian, whether warranted or not that he is not aware that he i s "away." Thi s i s t h e area of what psychiatry terms "hal l uc i n at i o n s " and d e l usionary states. Cor­ respon d i ng to these " u nn at u ra l " verbal activit ies, there are u n natu ra l bod i l y ones, where the i nd i v id u a l's activity i s patiently task-l i ke but not " u n derstand­ able" o r "mea n i ngfu l ." The u n n atural action may even i nvolve the h o l d i n g or

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grasping of someth i ng, as when an adu l t mental patient retai n s a ti ght hold on a dol l or a fetish l i ke piece of cloth. Here the terms "man nerism," " ritual act," or "posturing" are app l i ed, which, l i ke the term "un natura l," are c lear enough in their way but hardly tel l us with any specificity what it is that characterizes "natura l " acts. ( 1 964, pp. 75 76)

A t first glan ce, it wou ld seem that if there were ever a type o f behavior that in i tself wou l d be seen as abnormal, i t wou l d be "occ u l t i nvolvements." As Coffman notes, however, there is an element of cultural defi n ition even with "occ u lt i nvolvements": "There are societies i n which conversation w ith a spi rit not present i s as acceptable when susta i ned by properly authorized persons as i s conversation over a telephone in American soc iety" ( 1 964:79). Further­ more, he poi nts out that even in American society, there are occas ions i n wh i ch "occ u l t i nvolvement" i s not censured : "Those who attend a seance wou ld not consider it i nappropriate for the med i u m to i n teract with 'some­ one on the other si de,' whether they bel ieve th i s to be staged or a gen u i ne i nteraction . And certa i n ly we defi ne pray in g as acceptable when done at p roper occasions" ( 1 964, p. 79). Thus, ta l k i ng to spi rits and prayi n g to God are not i m proper i n themselves; i n deed, they are seen as legiti mate modes of activity when they fo l low the proprieties-that i s, when they occur i n the socia l ly proper c i rcumstances and are cond ucted by persons recogn i zed as legiti matel y, even though occu ltly, i nvolved . Two sign ificant i m p l ications fo l low from th i s d i scussion of the eti q u ette of i nvolvement. The fi rst i s that such psych iatric symptoms as withdrawal , ha l l uc i nations, cont i n u a l m utteri ng, a n d postu ring may b e catego ri zed as violations of certa i n soc i a l norm s-those norms so taken for gra nted that they are not expl icitly verbal ized, which we have cal led resi du al ru les. I n particular i nstances d i scussed here, the residual rule concerned i nvolvement in p u b l i c pl aces. It is true, of cou rse, that vari ous specific aspects of the i n ­ vol vement r u l e occasional ly a re fou nd, for example, i n books o f etiquette. Here, for example, is a typical proscription concern i ng i nvolvement with one's own person in p u b l i c p laces: Men should never look i n the m i rror nor comb the i r hair i n public. At most a man may stra ighten h i s necktie and smooth h i s hair with h i s hand. It is prob ably u n necessary to add that it is most unattractive to scratch one's head, to rub one's face or touch one's teeth, or to clean one's fingerna i l s in public. A l l these thi ngs should be done privately. (Fenwick 1 948, p . 1 1 ; quoted in Coffman 1 964)

A lthough we cou l d point to many such i nformal rules, it is i mportant to note that they are a l l s i tuationa l ly specific. There is nowhere cod ified a gen­ eral pri nciple of i nvolvement or even self-involvement. U n l i ke codified prin­ c i p l es, such as the Ten Command ments, i t i s one of those expectations that i t i s fel t should govern the behavior of every decent person, even though it

Residual Deviance

58

goes u nsaid. Because i t goes u nsaid, we a re not equ ipped by o u r c u l tu re to smooth l y categorize violations of such a rule but rather may resort to a res id­ ual catch a l l category of violations ( i .e., symptoms of mental i l l ness). Th i s i dea poi nts to the profoundly conservative tendency of the current conception of mental i l l ness. By putti n g the causes of residual deviance i n­ s ide the deviant, i t p rotects the current emotional/relational status quo. S i nce most people are h ighly i nvested in t h i s real m and u nwi l l i ng to cou ntenance i t, the concept of mental i l l ness offers them a way of avo i d i ng cons i dering the qual i ty of the i r feel i ngs and relations h i ps . I f i t proves t o b e correct that most symptoms of mental i l l ness c a n b e sys­ tematical ly classified as violations of cu ltura l ly particu lar normative networks, then these symptoms may be removed from the rea l m of u n iversal physical events, where they now tend to be p l aced by psyc h i atric theory, a long with other cul tu re-free symptoms such as fever, and may be investigated socio­ l ogically and anthropol ogically l i ke any other i tem of social behavior. A second i m pl ication of the redefin ition of psychiatric symptoms as resid­ ual deviance i s the great emphasis that th i s perspective pu ts o n the context in which the "symptomatic" behavior occu rs. As Coffma n repeatedly shows, "aways," "occul t i nvo lvements," and other k i nds of rule violations do not i n themselves bri ng forth censure; i t i s o n l y when social l y u n q u a l i fied persons perform these acts or perform them in i nappropriate contexts. That i s, these acts are objectionable when they occur in a manner that does not conform to the u n stated, but nevertheless operative etiquette that governs them. Al­ though recently psyc h i atric d i scussions of symptomatology h ave begun to d i splay cons i derable i nterest i n the social context, it is sti l l true that psych i ­ atric d iagnosi s tends t o foc us on t he pattern o f symptomatic behavior itself, to the neglect of the context i n wh ich the symptom occurs. The s ign ificance of th i s tendency in psych i atric d iagnostic p rocedu res i s d i scussed l ater. 1 The remainder of this chapter i s devoted to a d iscussion of the origi ns, preva­ lence, and cou rse of the behavior that we have defi ned here as residual ru le­ brea k i ng.

T H E O R I G I N S OF RES I D UA L RU LE-BREAKING

It is customary i n psych iatric research to seek a s i ngle generic sou rce or at best a s m a l l n u m ber of sources for mental i l l ness. The redefi n i tion of psy­ c h i atric symptoms as residual deviance i m med iately suggests, however, that there shou l d be an u n l i m ited n u m ber of sources of devi ance. The fi rst propo­ s i tion fol lows. Proposition 1 :

sources.

Residual rule-breaking a rises from fundamentally diverse

The Origim of Residual Rule-Breaking

59

Fou r d i sti nct types of sources are d i scussed here: orga n i c, psychological, ex­ terna l stress, and vol itional acts of i n novation or defiance. The o rga n i c and psychological origi n s of resid ua l ru l e-brea k ing are widely noted and are not d iscussed at l ength here. I t has been demonstrated repeatedly that particular cases of mental d i sorder had their origin in genetic, biochemical, or p hysio­ l ogical con d i tions. Psychological sources are a l so frequently i nd i cated : pe­ c u liarity of upbringing and t ra i n i ng have been reported often, particularl y i n the psychoan a l yt i c l iterature. The great majority o f preci se a n d systematic studies of ca u sation of menta l d isorder have been l i m i ted to either orga n i c o r psychol ogical sources. It is w i dely granted, however, that psychiatric symptoms can a l so ari se from external stress: from drug i ngestion, from the sustai ned fear and hard s h i p of combat, and from deprivation of food, sleep, and even sensory experience. Excerpts from reports on the consequences of stress w i l l i l l u strate the rul e­ break i ng behavior that i s generated by th i s less fam i l iar source. Physici an s have long known that toxic s ubstances can cause psychot i c- l i ke symptoms when i n gested i n appropriate doses. A wide variety of s ubstances have been the s u bject of experimentatio n i n produci ng "model psychoses." D rugs such as a mesca l i ne and LSD-2 5 , partic u l a r l y, have been described as prod u c i ng fa i rl y c lose rep l i cas of psych iatric symptoms, such as v i s u a l h a l l uci nations, loss o f orientation t o space a n d t i me, an d i nterference with thought processes. l lere i s a n excerpt from a report by a q ua l i fi ed psycholo­ gist who had taken LSD-2 5 : One concom itant of LSD that I shared with other subjects was distortion of the time sense. The subjective clock appeared to race. This was observed even at 25 m i l l igrams in counting 60 seconds. My tapping rate was a lso speeded up. On the l arger dose ( 1 /2 gra m ) my t i m e sense was d i splaced by hours. I thought the afternoon was wel l when it was o n l y 1 :00 P. M. I cou l d look at my watch and rea l ize the error, but I conti n ued to be d i soriented in ti me. The t i m e sense depends on t h e way time i s "fil led," and I was probably respon d i n g t o the qu ickened tempo of experience. Th is was in fact, my overwhel m i ng i m pression of LSD. Beg i n n i ng with the physiological sensations { l ightheartedness, excitement) I was shortly flooded by a montage of ideas, i m ages, and feel i ngs that seemed to thrust themselves upon of very bright thoughts, l i ke a fleeting i nsight i n to me unbidden. I had the psychotic process, which I wanted to write down. B ut they p ushed each other aside. Once gone, they could not be recaptured because the parade of new i m ages cou l d not be stopped. (C. C. Bennett 1 960, pp. 606 607)

The t i me d i sorien tation described is a fam i l iar psych iatric symptom, as i s t h e i deat i o n a l " pressure," w hic h i s u s ua l l y descr ibed as a feature o f m a n i c excitement. Combat psychosi s and psych i atric symptoms a ri s i ng from starvati o n have

60

Residual Deviance

been repeatedl y descri bed in the psyc h iatric l i terature. Psychotic symptoms res u l ti ng from s l eeplessness are l ess fam i l iar. One i n stance i s used to i l l us­ trate th i s reactio n . B rauchi and West ( 1 9 6 1 , p. 1 1 ) reported the symptoms of two participants i n a rad io marathon that req u i red them to tal k alternately every 3 0 m i n utes. After 1 68 hou rs, one of the contestants fel t that he and h i s opponent belonged to a secret c l u b of nonsleepers. H e accused h is gi rlfriend of kissing an observer, even though she was with h i m at the time. He fe lt he was be i ng p u n i s hed, had transient auditory and visual h a l l u c inations, and became suggesti ble, he and his opponent exh ib it i n g a period of folie a deux when the delusions and hal l uc i nations of the one were accepted by the other. He showed pers i s tence of h i s psychoti c symptoms, with del us ions about secret agents, and felt that he was responsible for the Israel-Egypt confl i ct. H i s reactions conta i n many elements that psych iatrists wou l d describe as paranoid and depress ive featu res. A number of stud ies have shown that deprivation of sensory sti mulation can cause h a l l uci nations and other symptoms. In one such study, Heron (1 961 ) re­ ported on subj ects who were cut off from sensations: Male college students were paid to l i e 24 hours a day on a comfortable bed in a l ighted sem i soundproof cubicle . . . wearing translucent goggles which adm itted diffuse light but prevented pattern vision. Except when eating or at toi l et, they wore cotton gloves and cardboard cuffs . . . i n order to l i m it tacti le perceptions. ( p. 8)

The subjects stayed from 2 to 3 days. Twenty-five of the 29 subjects reported h a ll uci nations, wh ich usua l ly were i nitially si mple and became progressively more complex over time. Three of the subj ects bel ieved their visions to be rea l : One m a n thought that h e saw th i ngs com ing a t h i m a n d showed head with drawa l quite consistently when th is happened; a second was convi nced that we were projecting pictu res on h i s goggles by some sort of movie camera; a th i rd felt that someone else was in the cubicle with h i m . (p. 1 7)

Merely monotonous envi ron ments, as i n l ong-distance drivi ng or flyi ng, are now thought to be capab le of generati ng symptoms. The fol l owi ng excerpt is taken from a series on psychiatric symptoms in m i l itary aviation: A pi lot was fly i ng a bomber at 40,000 feet and had been conti n u i ng straight and level for about an hour. There was a haze over the ground that prevented a proper view and rendered the horizon i n d i sti nct. The other member of the crew was sitti ng i n a sepa rate place out of the p i l ot's view, and the two men d i d not ta l k t o each other. Suddenly t h e pi lot felt detached from h i s surroundi ngs and then had the strong i m press ion that the a i rcraft had one wing down and was turni ng. Without consulting his i nstruments h e corrected the attitude, but

The Origins of Residual Rule-Breaking

61

t h e a i rcraft went to a s p i ra l di ve because it had i n fact been fly i n g stra i ght and leve l . The pi lot was very l u cky to recover from the s p i ral clive, and when he l anded the a irirame was foun d to be cl istortecl [from the stress caused by the d i ve ! . On exam i n i ng the p i l ot, n o psych iatric abnorma l ity was fou n d . . . . A s the m a n h a d no wish to give up flying a n d was in fact physica l l y a n d menta l l y fit, he was offered a n expla nation of the phenomenon and was reassured. H e re­ t urned t o flyi n g duties . (A. M . H . Bennett 1 96 1 , p. 1 66)

In thi s case, the symptoms (depersonal i zation and spatial disorientation), occurring as they did in a real-l ife situation, could eas i l y h ave resulted in a fatal accident. I n l aboratory studies of model psychoses, the consequences a re usu a l l y easi ly control led. Particu larly relevant to thi s d iscussion i s the role of reassurance of the subject by the experi menter, after the experi ment is over. I n a l l of the laboratory stud ies (as in this last case as wel l), the persons who have had "psychotic" experiences a re reassured; they are told, for example, that the experiences they had were solely due to the situation that they were p laced i n, and that anyone else placed i n such a s i tuation wou l d experience s i m i l a r sensations. In other words, the i mp l i cations of the ru le-breaking for the ru le-breaker's social status and self-conception a re "normal i zed." Sup­ pose, however, for pu rposes of a rgument, that a d iabol ical experi ment was performed i n which subjects, after having exh ib i ted the psychotic symptoms u nder stress, were "labeled ." That is, they were told that the symptoms were not a normal reaction, but a rel iable indi cation of deep-seated psychologi­ cal d i sorder i n their personal i ty. S uppose, in fact, that such l abel i ng were conti n ued i n their ord i nary l i ves. Wou l d such a l a be l i ng p rocess stabi l ize rule-break i ng that wou l d have otherwi se been tra n sitory? This question is con s i dered u nder Proposition 3, fol lowi ng, and in C hapter 5 . Ret u rn i ng t o the consideration o f origins, r u l e-breaking fi n a l ly c a n be seen as a vol i tional act of i n novation or rebe l l i o n . Two examples from art h is­ tory i l l u strate the del iberate brea k i ng of res i d u a l ru les. It is reported that the early reactions of the critics and the publ i c to the paintings of the French i mpressioni sts were ones of d isbel ief and d i smay; the colors, particularly, were thought to be so u n real as to be evidence of m ad ness. I t is i ronic that i n the ensuing struggle, the Impressi o n i sts and their fol lowers effected some changes in the color norms of the publ ic. Today, we accept the colors of the I mpressionists without a second glance. The Dada movement p rovides an example of an a rt movement del iber­ ately conceived to violate, and thereby reject, ex ist ing standard s of taste and val ue. The jewel-encrusted book of Dada, which was to contai n the greatest treasures of contemporary civilization, was found to be fil led with toilet paper, grass, and s i m i lar m aterials. A typical objet d'art produced by Dadaism was a fu r- l i ned teacup. A c l imactic event i n the movement was the Dada Exposi­ tion given at the Berl i n Opera House. All of the celebrities of the German a rt

62

Residual Deviance

world and d i g n i taries of the We i m a r Repu b l i c were i nv i ted to atten d the open ing n ight. The first i tem of the even in g was a poetry-read ing contest, i n which there were fourteen contestants. Since the fou rteen read their poems s i m u ltaneously, the evening soon ended in a riot . T he exam ples o f res idual rule-brea k ing g iven here are n o t presented as scientifi ca l l y i mpeccable i n stances of th i s type of behavior. There are many problems conn ected with rel i ab i l i ty in these areas, parti cu la rly with the material on behavior res u l t i ng from drug i ngestion a n d sleep and sensory deprivation. Much of t h i s material i s s i m p l y c l i n ical or a u to bi ograph i cal i mpressions of s i ngle, isolated i nstances. I n the studies that have been con­ d ucted, i nsufficient attention i s usually paid to research design, systematic tec h n iques of data co l lection, and devices to guard agai nst experi menter or s u bject b ias. Of the many questions of a more general nature that are posed by these examples, one of the more interesting i s, Are the "model psychoses" produced by d rugs or food, sleep, or sensory deprivation actu a l l y i dentical to "n atura l " psychoses or, on t h e other hand, are t h e s i m i l a ri ties o n l y su perfic i a l , mask­ i ng fu ndamental d i fferences between the laboratory and the natura l ru le­ breaki ng? The opin ions of researchers are spl i t on t h i s issue. Many i nvestiga­ tors state that model and real psychoses are basica l l y the same. Accordi ng to a report i n the autobiograp hic a l, c l i n ical, and experi mental accou nts of sensory deprivation, B l eu ler's card i n a l symptoms of schi zophre n i a frequently appear: d i sturbances of assoc iations, d isha rmony of affect, autism, ambiva­ lence, d isruption of secondary thought processes accompa n i ed by regression to primary processes, i mpai rment of rea l i ty-testing capaci ty, di stortion of body i mage, deperso n a l ization, delusions, and h a l l uci n ations ( Rosenzweig 1 9 59, p. 3 2 6) . Other researchers, however, i ns i st that there are fundamental d iffer­ ences between experi mental and gen u i ne psychoses. The controversy over model psychoses prov ides evidence of a basic d iffi­ culty in the scientific study of menta! d isorder. Although there is an enormous l iterature on the description of psyc h i atric symptoms, at th i s writi ng scientif­ ica l ly respectable descriptions of the major psyc h i atric symptoms, that i s to say, desc riptions that h ave been s hown to be prec i se, rel iable, and val id, do not exist (Scott 1 95 8, pp. 2 9-45 ) . I t i s not o n l y that studies that demonstrate the preci s ion, rel iabi l i ty, and val id i ty of measures of symptomatic behavior h ave not been m ade, but that the very basi s of such stu d i es, operational def­ i n itions of psyc h i atric symptoms, h ave yet to be form u l ated. I n physical med­ ic i ne, there are i nstruments that yield easi l y verified, repeatable meas u res of d i sease symptoms; the thermometer used in detecti ng the presence of fever is an obvious example. The analogous i nstruments i n psych i atric medi ci ne, q uestionnai res, behavior rati n g scales, etc. , which yield verifiable measu res of the presence of some symptom pattern (e.g., paranoid i deation), h ave yet to be fou nd, tested, and agreed u po n .

63

Prevalence

I n the absence of scientifi ca l l y acceptable evidence, we can o n l y rel y on our own assessment of the evidence in conj u nction with our appraisal of the confl i cting op i n ions of the psyc h i atric i nvestigators. I n t h i s case, there i s at present no conclusive answer, but the weight of evidence seems to be that there i s some l i ke l i hood that the model psychoses are not basi c a l l y d i s s i m i ­ la r t o ord i nary psychoses. Therefore, i t appears that t h e fi rst proposition, that there a re many di verse sources of residual rule-breaking, i s su pported by ava i lable knowledge.

PREVALENCE

The second proposition concerns the prevalence of residual rule-brea k i ng i n entire and ostens i b l y normal pop u lations. Th i s prevalence i s rough l y anal­ ogous to what medi cal epidemiologists ca l l the "tota l " or "true" prevalence of mental symptoms. Proposition 2 : Relative to the rate of treated mental illness, the rate of unrecorded residual rule-breaking is extremely high.

There is evidence that gross viol ations of rules are often not noti ced or, if no­ ti ced, are rationa l i zed as eccent r i c i ty. Apparently, many person s who are extremely w ithdrawn or who "fly off the hand le" for extended periods of ti me, who i magi ne fantast ic events, or who hear voi ces or see vision s, are not labeled as i nsane either by themselves or others.2 The i r rule-breaking, rather, i s u n recogni zed, ignored, or ration a l i zed . Th i s pattern of i n attention and ra­ tion a l i zation is cal led "normal ization."3 I n addition to the kind of evi dence j u st c i ted, there are a n u m ber of epi­ demiological stu d i es of total preva lence. There are n u merous problems i n i nterpreti ng the res u l ts of these studies; the major d ifficu l ty i s that the defi n i ­ tion of mental d i sorder i s d ifferent i n each study, as are the methods used to screen cases. These studies represent, however, the best ava i l able i nformation and can be u sed to esti mate total prevalen ce. A conven ient summary of fi ndi ngs i s presented in P l u n kett and Gordon ( 1 960) . These authors compare the methods and pop u l ations used in 1 1 field studies and l ist rates of total prevalence as 1 . 7, 3 . 6, 4.5, 4 . 7, 5 . 3 , 6 . 1 , 1 0 . 9, 1 3 .8, 2 3 .2 , 2 3 . 3 , and 3 3 . 3 % . S i n ce the P l u n kett and Gordon review was p u b l ished, two elaborate stud­ ies of symptom preval en ce h ave appeared, one in Manhattan, the other i n N ova Scoti a (Srole e t a l . 1 962 ; Leighton e t a l . 1 963 ) . I n the M idtown Man­ hattan study, i t is reported that 80% of the sample c u rrently had at least one psych iatric symptom. Probably more comparable to the earl ier stu dies i s their rat i n g of " i mpa i red because of psych iatric i l l ness," which was appl ied to

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Residual Deviance

2 3 .4% of the popu latio n . In the Sti r l i ng Cou n ty, Nova Scotia, stu d i es, the esti mate of current p reva lence i s 5 7%, with 2 0 % classified as "psych i atric d i sorder with sign ificant i mpai rment." How do these tota l rates compare with the rates of treated mental d i sor­ der? One of the studies cited by P l u n kett and Gordon, the Balti more study reported by Pasamanick ( 1 963, pp. 1 5 1 -1 5 5 ) , is usefu l in t h i s regard s i nce i t includes both treated a n d u n treated rates. As compared with t h e u ntreated rate of 1 0 . 9%, the rate of treatment in state, VA, and private hospitals of B a l ­ ti more resi dents was 0 . 5 % ( i b i d . , p. 1 5 3 ) . That i s, for every mental patient there were approxi mately 2 0 u ntreated persons l ocated by the su rvey. It is possi bl e that the treated rate is too l ow, however, si nee patients treated by private phys icians were not i nc l u ded. Judging from another study, the New H aven, Con necti cut, study of treated p reva lence, the n u mber of patients treated in private p ractice i s smal l in comparison with those hospital i zed : over 70% of the patients located i n that study were hospita l i zed even though extens ive case-fi n d i ng tech n i q ues were employed. The overa l l treated preva­ lence i n the N ew Haven study was reported as 0 . 8%, a figu re that is in good agreement with my est imate of 0 . 7% for the Balti more study (Hol l i ngshead and Red l ich 1 95 8 , p. 1 9 9 ) . If we accept 0 . 8 % as an est i m ate of the upper l i mi t of treated preva lence for the Pasaman ick study, the ratio of treated to u ntreated patients i s 1 : 1 4 . That is, for every patient we should expect to fi nd 1 4 untreated cases in the comm u n ity. One i nterpretation of th i s fi n d i ng is that the u ntreated patients in the com­ m u n i ty represent those with less severe d isorders, wh i le patients with severe i mpai rments a l l fal l i nto the treated group. Some of the fi ndi ngs in the Pasa­ m a n i c k study poi nt in th i s d i rect i o n . Of the u ntreated patients, about half are classified as psychoneurotic. Of the psychoneurotics, in turn, about half aga i n are c lass ified as sufferi ng from m i n i ma l i m pa i rment. At least a fou rth of the u ntreated group, then, i nvolved very m i l d d isorders (Pasamanick 1 963, pp. 1 5 3-1 54). The evidence from the group d iagnosed as psychotic does not support th i s i nterpretation, however. A l most a l l of t h e persons d i agnosed a s psychotic were j udged to have severe i mpai rment, yet half of the d i agnoses of psychosi s occurred i n t h e u ntreated group. I n other words, accordi ng t o th i s study, there were as many u ntreated as treated cases of psychoses ( i b i d . ) . I n t h e Manhattan study, a d i rect comparison b y age group was made be­ tween the most deviant group (those classified as " i ncapac i tated") and per­ sons actual l y receiving psych i atric treatment. The res u l ts for the groups of younger age (2 0-40 years) is s i m i lar to that i n the Pasamanick study: Treated p reva lence is rough ly 0 . 6%, and the proportion classified as " i ncapacitated" is about 1 . 5 % . In the o lder age grou p, however, the ratio of treated to treat­ able changes abruptly. The treated preva lence is about 0 . 5 %, but 4% are des-

The Duration and Consequences of Residual Rule-Breaking

65

ignated as " i ncapacitated" i n the pop u l ation. I n the older gro u p, therefore, the ratio of treatable to treated (Sro l e et a l . 1 9 62) is about 8 : 1 . Once agai n, becau se of l ack of complete comparabi l i ty between studies, confl icti ng res u l ts, and i nadequate research designs, the evi dence regardi ng prevalence i s not conc l u sive. The existing weight of ev i dence appears, how­ ever, very strongly to support Proposition 2 .

T H E D U RATION A N D CONSEQU E N CES O F RESI D UA L RULE-BREAKI NG

In most epidemiological research, i t is frequently assumed that treated prevalence is an exce l l ent i ndex of total preva l ence. The commun ity studies previously d iscussed, however, suggest that the majority of cases of " mental i l l ness" never receive medical attention. Thi s fin d i n g has great significa nce for a cruc i a l q uest i on about resi d u a l devia nce: given a typ ical i n stance of res i d u a l ru l e-break i ng, what i s its expected cou rse and consequences? O r, to p u t the same question i n medical language, what i s the prognosi s for a case i n which psych i atric signs and symptoms are evi dent? The usual working hypothesi s for physicians confronted with a sign or symp­ tom is that of progressive development as the i nner logic of d i sease u nfol ds. The medical framework t hu s l eads one to expect that u n less med ical i n ter­ vention occ u rs, the signs and symptoms of d i sease are usual l y harb i ngers of further, and more serious, con sequences for the i nd ividual show i n g the symptoms. This is not to say, of course, that p hys icians th i n k of a l l symptoms a s bei ng parts of a progress ive d i sease pattern; w i tness the concept of the " be n ign" condi ti on. The po i nt is that the i magery that the medi ca l model cal l s u p tends to predi spose the p hys i cia n toward expect i ng that symptom s are but i n itial signs o f further i l l ness. The fi n d i n g that the great majority of persons d isplayi n g psyc h i atric symp­ toms go u ntreated leads to the th i rd proposition. Pro p osition 3:

Most residual rule-breaking is normalized and is of tran

significance.

The enormously h igh rates of total prevalence that most residual rule­ breaking i s u n recog n i zed or rational i zed away. For thi s type of rule-break i ng, w h i ch is amorphous and u ncrysta l l ized, Lemert u sed the term "primary dedescri bes s i m i lar behavior viation" ( lemert 1 95 1 , C hapter 4 ) . Ba l i nt ( 1 A lthough B a l i n t assumes that as "the u norga n i zed phase of i l lness" ( p . 1 patients in th i s phase u lti mately "settle down" to a n "organ i zed i l l ness," other outcomes are possible. A person in this may "organ ize" h i s deviance i n

66

Res id u a l Deviance

other than i l l ness terms a s eccentr i c i ty or gen ius), or the ru l e-breaking may termi nate when situational stress i s removed. The experience of battlefield psych iatrists can be i n terpreted to support the hypothesi s that residual rule-breaki n g is u s ually transitory. G l ass (1 9 5 3 ) reports that combat neurosi s is often self-term i nating if the soldier is kept with h is u n it and given o n ly the most s uperficial medical attention .4 Descriptions of child behavior can be i nterpreted in the same way. Accord i ng to these reports, most c h i l dren go through periods in which at least several of the fol lowing k i nds of rule-brea k i ng may occur: temper tantrums, head bangi n g, scratchi ng, p i nch­ i ng, biting, fantasy playmates or pets, i l l usory physical complaints, and fears of sounds, shapes, colors, persons, a n i ma l s, darkness, weather, ghosts, and so on ( l l g and Ames 1 960, pp. 1 3 8-1 88). I n the vast majority of i nstances, how­ ever, these behavior patterns do not become stable. There a re, of course, cond i ti o n s that do fit the model of a p rogressively u nfo l d i n g d isease. In the case of a patient exh i b i ti ng psychiatric symptom s becau se o f general paresi s, t h e early s i g n s and symptoms appear t o be good, though not perfect i nd icators of l ater more serious deteriorat i on of both p hys­ ical health and soc i a l behav i o r. Conditions that have been demonstrated to be of t h i s type are rel ative l y rare, however. Paresis, which was once a major category of mental d isease, acco u n ts today for only a very m i no r p roportion of menta l patients u nder treatment. Proposition 3 wou l d appear to fit the great majority of mental patients, i n whom external stress such as fam i ly confl i ct, fatigue, drugs, and s i m i l a r factors are often encoun tered . Of the f i rst t h ree p roposi t i ons, the last i s both the most crucial for the theory as a whole and the least wel l s u pported by ex isting evidence. It i s not a matter of there bei n g amounts of n egative evidence, show i n g that psy­ ch i atric symptoms are rel i a b l e i n d i cators of su bsequ ent d isease, but that there i s I i ttle evidence of any k i n d concer n i ng deve l opment of symptoms over ti me. There are a n u m ber of analogies i n the h i story of p hys ical medi c i ne, For example, u nt i l the late 1 940s, h i stoplasmosis h owever, that are was thought to be a rare trop i ca l d i sease with a u ni formly fata l o utcome (Schwartz and B a u m 1 B u t i t was l ater discovered that it i s w i dely preva­ lent and with fatal o utcome or even i mpai rment extremely u nu s u a l . It i s conceivable that most 11menta! i l lnesses// may prove to fol low t h e same pat­ tern when adequate longitudi n a l stu d i es of cases in normal pop ulations have been made. I f residual ru l e-breaking is h i g h l y prevalent a mong ostens i b l y "norm a l " person s a n d i s usual l y t ransito ry, as suggested b y t h e l ast two p ropositions, what accou nts for the small percentage of residual rule-breakers who go o n t o deviant careers? To put t h e q uestion another way, u nder what conditions i s res i d u a l ru le-breaki ng stabi l i zed? The conventional hypothesi s i s that the answer l ies in the r u l e-breaker h i mself. The hypothesi s suggested here i s that :J.n i m portant factor (but not the o n l y factor) in the sta b i l i zation of residual

Notes

67

ru le-break i ng is the societal reaction. Residual rule-breaking may be stabi­ l i zed i f it is defined to be evidence of mental i l l ness and/or the rule-breaker is p laced in a deviant status and begins to play the role of the menta l l y i l l . In order to avoi d the i m p l i cation that mental disorder is merely role-playing and pretense, i t is n ecessary to d i sc uss the social i nstitution of i nsani ty i n the next chapter.

NOTES See Chapter 1 0 on the relationsh i p between symptoms, context, and mea n i ng. See, for example, C lausen and Yarrow ( 1 955), Hol l i n gshead and Redl ich ( 1 9 5 8, pp. 1 72 -- 1 76), a n d E . C u m m i ng and ] . C u m m i n g (1 9 5 7. pp. 92 1 03}. 3. The term denial i s used in the same sense a s in C um m i ng and C u m m i ng ( 1 9 5 7 , Chapter 7}. 4. Cf. Kard i ner and S p i egal ( 1 94 7, Chapters 3-4). 1.

2.

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5 The Social I nstitution of I nsanity

A mong psych i atri sts, Szasz has been the most outspoken critic of the use of the med ical model when app l i ed to " mental i l l ness." H i s criticism has taken the form that mental i l l ness is a myth that serves functions that are l argely non­ medical in nature: Our adversaries are not demons, witches, fate, or mental i l l ness. We have no enemy whom we can fight, exorci se, or d i spel by "cure." What we do have are problems in l ivi ng whether these be biologic, econom ic, pol itica l , or socio psychologi ca l . . . . The field to which modern psychi atry add resses itself i s vast, and I made no effort to encompass it a l l . My argument was l i m ited to the proposition that mental i l lness is a myth, whose fu nction it i s to d isgu ise and thus render more palatable the bitter p i l l of mora l confl i cts in human rela tions. ( 1 960)

Szasz's form u lations of the social, nonmedical functions that the i dea of mental i l l ness is made to serve are cl ear, cogent, and convi nci ng. H i s con­ ceptua l i zation of the behavior that is symptomatic of "menta l i l l ness," how­ ever, is open to criticisms of a soc i a l-psychological nature. I n the "Myth of Mental I l l ness" ( 1 960) Szasz proposes that mental di sorder be viewed with i n the framework of "the game-play in g model of h u m an be­ havior" (pp. 1 1 3-1 1 8) . He then describes hysteria, sch i zophren i a, and other mental di sorders as the " impersonation" of sick persons by those whose "real" 69

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The Social institution of I nsan ity

problem con cern s "problems of l iv i ng." Although Szasz states that role­ p layi ng by mental patients may not be comp letely or even mostly vo l u ntary, the i mpl ication i s that mental d isorder be viewed as a strategy chosen by the i ndividual as a way of obtai n i ng help from others. Thus, the term imperson a tion suggests calcu l ated and de l i berate sham m i ng by the patient. Although he notes di fferences between behavior patterns of hysteria, m a l i ngeri ng, and cheati ng, he s uggests that these d i fferences may be mostly a matter of whose poi nt of view is taken in describing the behavior.

I N DIV I D UA L A N D I NTERPERSONAL SYSTEMS IN ROLE-PLAY I N G

The present d i scussion also uses t h e role-play i ng model t o analyze mental d isorder but places more emphasis on the i nvol u ntary aspects of role-play i ng than Szasz, who tends to treat role- p l ay i n g as an i nd ividual system of be­ havior. I n many social-psychological d i scussion s, however, role-playi n g i s considered a s a part of a soc ia l system. The i nd ividual plays h i s role by ar­ ticulating h i s behavior with the cues and actions of other persons i nvolved i n the transaction. The p roper performance of a ro le i s dependent o n having a cooperative audience. The p roposition may a l so be reversed : Hav i ng an au­ d ience that acts toward the i ndividual in a u niform way may l ead the actor to pl ay the expected ro le even if he is not particu larly i nterested in doing so. The "baby of the fam i ly" may come to fi nd th i s role obnoxious, but the u n i ­ form pattern o f cues a n d actions that confronts h i m i n the fam i l y may lock i n with h i s own vocabul ary o f responses s o that i t i s i nconven ient a n d di ffi c u l t for h i m n o t t o pl ay t h e part expected o f h i m . To t h e degree that alternative roles are closed off, the p roffered role may come to be the o n ly way the i n­ d ividual can cope with the s i tuation. One of Szasz's very apt formu lations touches upon the soc i a l-system i c as­ pects of ro le-playi ng. Szasz ( 1 960) d raws an analogy between the role of the mental l y i I I and the "type-casting" of actors. 1 Some actors get a reputation for p l ay ing one type of role, and find it d iffi c ul t to obtai n other roles. Although they may be d i s pleased, they may a l so come to i ncorporate aspects of the typecast role i nto their self-conceptions and u lti mately i nto the i r behavior. Fi ndings i n several social-psychological stud ies ( B iau 1 956; Benjam i ns 1 950; E l l i s 1 945; Lieberman 1 956) suggest that an i ndividual's role behavior may be shaped by the kinds of "deference" that he regularly receives from others.2 One aspect of the vol u ntari ness of role-play ing is the extent to which the actor be l ieves in the part he i s play i ng. A lthough a role may be pl ayed cyn i ­ cal l y, w i t h no bel i ef, or comp letely s i n cerely, w i t h wholehearted bel ief, many roles are pl ayed on the basi s of an i ntricate m i xture of bel i ef and d isbel i ef. D u ri ng the course of a study of a large p u b l i c mental hospital, several pa­ tients told the author i n confidence about their cyn ical use of thei r symptoms-

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71

t o frighten new personnel, t o escape from unpleasant work deta i ls, a n d s o on. Yet, at other t i mes, these same patients appear to have been s i ncere i n their symptomatic behavior. Apparently, i t was someti mes di ffi c u l t for them to tel l whether they were play i ng the role o r the role was playi n g them . Certai n types o f sym ptomatology are q u i te i nteresti ng i n th i s con nectio n . I n cases of patients s i m u lat i ng previous psychotic states and in the behavior pattern known to psych i atrists as the Ganser syndrome, it is apparently a l most i m­ possible for the observer to separate feigning of symptoms from i nvol untary acts with any degree of certa inty. The fol l owi ng case h i story excerpt from Sadow and S u s l ick ( 1 9 6 1 ) w i l l i l l u strate what psych i atri sts have cal led s i m u lation of a previous psychotic state: A 3 2 year-old wh ite man, an engineer, was readm itted to the hospital be cause of the recurrence of psychotic behavior. He had been hospital ized twice previously. The fi rst t i me he had had electroshock treatment and had a rem i s­ sion for 4 years. One of us . . . saw h i m during h i s second hospital ization. At that t i me he was severely regressed, h a l l uci nating freely, had magical and delu­ sional behavior and many ideas of a messianic nature. He made a good func tional recovery after several months of intensive psychotherapy by his private psych iatrist, supplemented with i n su l i n coma treatment. Several years later he had a recu rrence of symptoms and, because of my acquai ntance with h i m d u ri ng the previous hospital i zation, h e was referred by h i s previous therapist. On adm i ssion h i s behavior was bizarre enough to warrant sen d i ng h i m to the d istu rbed u n it. There he i m med iately took over the u n i t c l a i m i n g seniority rights because of h i s previous stay. When seen he was jov i a l l y patro n i z i ng, referred to h i s voices in a s m i l i ng manner and i nterspersed the i nterview with vague magical i nferences of seem i ngly great s i gn ificance. He conti n u a l l y made a parti cular gesture, that of a c lock with the hands at the 6 o'clock position. Th i s gesture h a d been t h e subj ect o f m u c h i nq u i ry and work on h i s previous ad m ission . As a resu l t of the prior contact, it was possible to be more d i rect and i nq u i ri ng w ith him than if he had been a new pati ent. At th i s point he gave no i n di cations as to the precipitating sti m u l u s of d i sruptive confl i ct. During some bantering in which he referred to h i s cu rrent hospital i zation as a vacation, or a return of the old grad to h i s A l ma Mater, he was told that th i s m i ght prove to be an expensive class reun ion. (Th is was in reference to one of h i s ostensible rea sons for d i sconti n u i n g psychotherapy fol l ow i ng h i s previous d isorder, namely, that treatment was too costly.) With a l most d ramatic swiftness fol l ow i ng th i s remark, h i s bizarre behavior stopped and became qu ite depressed although sti I I comm u n i cative. The fol lowing day it was possi ble t o transfer h i m t o a less con­ trol led u n i t and he descri bed in a completely coherent fashion with i ntense but appropriate emotion that he was extremely angry with his wife for nagging and bel ittl i ng h i m . He was afrai d he wou ld not be able to control h i mself and felt that if he were sick l i ke the last time he could avoid a feared outburst of phys i cal violence by bei ng hospital ized. In a few days he was able to recognize that much of the rage at h i s w ife was d i rected at her cu rrent pregnancy. Although a

72

The Social Institution of I nsan ity moderate depression persisted, there was no recurrence of the bizarre behavior or the apparent h a l l uci nations. He left the hospital after 3 weeks and returned d i rectly to h i s job and home. (pp. 452 458)

What ma kes "si m u l ation" particu larly relevant to a soci al-systemic theory of menta l i l l ness is that it is bel i eved that such behavior is usually a defen­ sive reaction to external stress: " [Th i s cond ition] cons i sts of vary i ng degrees of conscious s i m u lation of the previous psychotic state by an d u n der the control of the patient's ego when a su bsequent s i tuation of stress occurs" ( Sadow and Suslick 1 96 1 , p. 4 5 2 ) . This psych i atric defi n i tion closely paral­ lels Lemert's ( 1 9 5 1 ) sociological defi n ition of "secondary deviation": "When a person begi ns to employ h i s deviant behavior or a ro le based upon it as a means of defen se, attack, or adj ustment to the overt and covert prob lems cre­ ated by the consequent societal reaction, h is deviation is secondary" (p. 76). Moreover, i t appears that such s i m u l ation can occur even where there has been no previous psychotic epi sode: A particularly stri king example of this was seen in a young hospital record custod ian who developed a complex of subjective symptoms h ighly suggestive of a frontal lobe bra i n tumor. Laboratory and physical tests short of air stud ies had revealed that her difficulties were of a conversion l i ke nature and were i n part patterned after case histories that s h e h a d read with more d i l i gence than cal led for by her job. (Sadow and Sus l ick 1 961 , p. 4 5 3 )

Apparently, one can play the rol e of a menta l l y i l l person without ever h av­ ing actual l y experienced the ro le. Vicarious learn i ng of imagery of the role of the menta l ly i l l w i l l be d i scussed shortly in the section fol l owi ng Proposi­ tion 5 . The Ganser syndrome appears to i l l u strate the i ntri cate man ner i n which vo l u ntary and i nvo l u ntary elements i ntertwi ne i n role-pl ay i ng. Th i s condition i s referred to by psyc h iatri sts as the "approxi mate answer" or Vorbeireden (ta l king past the point) syndrome: The patient is d i soriented as to time and space and gives absurd answers to questions. Often he claims he does not know who he is, where he comes from, or where he i s . When he is asked to do simple calcu lations, he makes obvious m istakes for instance, giving 5 as the sum of 2 p l us 2. When he is asked to identify objects, he gives the name of a related object. U pon being shown scis­ sors, the patient may say they are knives; a picture of a dog may be identified as a cat, a yel low object may be called red, and so on. If he is asked what a hammer is used for, he may rep ly to cut wood . If he is shown a d i me, he may state that it is a half dollar and so on. If he is asked how many legs a horse has, he may reply, "Six." At ti mes al most a game seems to go on between the exam i ner and the pa­ tient. The exam i ner asks questions that are almost s i l l y in their s i m p l i city, but

Individual and Interpersonal Systems in Role-Playing

73

the patient succeeds i n givi ng a s i l l ier answer. And yet it seems that the patient u nderstands the question, because the answer, a l though wrong, i s related to the question. (Arieti, S i l vana, and Meth 1 959, p. 547)

In accordance with what has been said here about the soci al -systemi c na­ t u re of role-play i ng, the d iffic u l ty in i nterpreti ng s i m u l ation of previous psy­ chotic states, and the Ganser synd rome, is that the patient is j u st as confused by h i s own behavior as is the observer. Some psych iatrists suspect that i n sch i zophrenia there is a l arge element of behavior that i s in the borderl i ne zone between vol itional and nonvo l i ­ t i o n a l activity. Here are some excerpts from an autobiographical account of sch izophren ia that stress the role-play ing aspects: We sch i zophrenics say and do a lot of stuff that is u n i mportant, and then we m i x i mportant th i ngs in with a l l this to see if the doctor cares enough to see them and feel them. Patients l augh and posture when they see through the doctor who says he wi l l help but rea l ly won't or can't. . . . They try to please the doctor but a l so confuse h i m so he won't go i nto anyt h i ng i m portant. When you find people who w i l l rea l l y help, you don't need to d i stract them. You can act in a normal way. I can sense if the doctor not only wants to help but also can and w i l l help . . . Patients kick and scream and fight when they aren't sure the doctor can see them. It's a most terrifying feel i ng to rea l i ze that the doctor can't understand what you feel and that he's j ust going ahead with h i s own ideas. I wou ld start to feel that I was i nvisible or maybe not there at a l l . I had to make an uproar to see if the doctor wou ld respond to me, not just h i s own ideas. ( Hayward and Taylor 1 956, p. 2 1 1 )

N ote that th i s patient has app l ied to herself a deviant label ("we sch i zo­ p h re n ics"), and that her behavior fits Lemert's defi n ition of secondary devia­ tion; she appears to have u sed the deviant role as a mea ns of adj u stment. Th i s d i scussion suggests that a stable role performance may arise when the actor's ro le i magery l ocks in with the type of "deference" that he regu larly re­ ceives. An extreme example of th i s process may be taken from anthropol og­ ical and med ical reports concerning the "dead role," as i n deaths attri buted to "bone-poi nti ng." Death from bone-poi nti ng appears to arise from the con­ j u nction of two fundamental processes that characterize a l l social behavior. Fi rst, a l l i nd ividuals cont in ua l ly orient themselves by mea ns of responses that are perceived in social i nteraction: The i nd ividual's identity and conti n u ity of experience are dependent on these cues. Genera l i z i ng from experi mental fi ndi ngs, B la ke and Mouton ( 1 9 6 1 ) make th i s statement about the processes of conformi ty, res i stance to i nfluence, and conversion to a new role:

The Soc i a l I nstitution of I n sa n i ty

74

An i nd i v i d u a l requ i res a sta b l e framework, i nc l u d i n g sa l ie n t and firm refer ence poi n ts, i n order to o r i e n t h i mself and to regul ate h i s i nteractions w i t h others. Th is framework consists o f external a n d i ntern a l a nchorages ava i la b l e t o the i nd i v i d u a l whether he i s aware o f t h e m or not. W i t h a n acceptabl e frame work he can resist g i v i n g or accepting i nformation that is i n consi stent with the framework o r that requ i res him to rel i nq u i sh it. In the absence of a sta b l e frame­ work he actively seeks to estab l is h one through h is own s trivi ngs by m a k i n g use of s i g n i ficant a n d releva n t i nformation provided withi n the context of i n terac tion. By contro l l i n g the amount a n d k i nd of i n formation ava i l a b l e for orienta tion, he can be led to embrace conform i n g attitudes wh i c h are enti rely forei g n t o h i s e a r l ier ways o f t h i n k i ng. (pp. 1 2 )

Second, the i nd ividual has his own vocabulary of expectations, which may i n a particular s i tuation either agree with or be in conflict with the sanctions to which he is exposed. Entry i n to a role may be complete when this role is part of the i nd ividual's expectations and when these expectations are reaf­ firmed in social i nteraction . In the following pages, this principle is appl ied to the problem of the cau sation of mental d isorder, through consideration of the soci a l i nstitution of i nsani ty.

LEARNING AND MAINTAINING ROLE IMAGERY

What are the bel iefs and p ractices that constitute the social i nstitution of i n­ sanity? And how do they figure i n the development of mental di sorder? Propo­ sitions 4 and 5 concern i ng beliefs about mental d isorder in the general public are now considered . Proposition 4:

Stereotyped imagery of mental disorder is /earned in early

childhood.

A l though there are no s u bstantiating stu d i es i n this a rea, scattered observa­ tions l ead the a uthor to conclude that ch i l dren learn a considerable amou nt of i magery concerni ng deviance very early, and that much of the i magery comes from thei r peers rather than from a d u l ts. The l i teral mean i ng of crazy, a term now u sed i n a wide variety of contexts, i s probab l y grasped by c h i l ­ dren d u r i ng the first years o f elementary schoo l . S ince adu lts are often vague and evas ive in the i r responses to questions in th i s area, an a u ra of mystery su rrounds it. I n t hi s soc i a l i zation, the grossest stereotypes t h at are heir to c h i l d hood fears (e.g., the bogeyman) survive. These con c lusions a re qu i te spec u l ative, of cou rse, and need to be i nvesti gated system at ic a l l y, possi bly with techn iques s i m i lar to those used in stud ies of the ear l y learni ng of racial stereotypes. Here are some psychiatric observations on "playing crazy" i n a group of c h i l d patients (Ca i n 1 964). Th i s material indicates that the soci a l stereotypes

Learning and Maintaining Role Imagery

75

8-1 2 ) and play an active part i n thei r cogni ­ are held by these c h i l dren tion a n d behavior. I t a lso fits the precedi ng d i scussion o f role-playing a n d secondary deviation. Equa l l y pro m i nent are their i n tense concerns about c ra z i ness, about t h e pos­ s i b i l ity that they themselves are crazy. . . . Th i s concern seems to reflect the c h i ld ren's response to their own sporadic psychoti c experience and behavior, a soc i a l awareness of how they appear to others, and perhaps i n a sense an attempt to "explai n " thei r own behavior. U ndoubtedl y, they are a l so reacti n g to teasi n g a n d n ame-ca l l i n g by peers, and exasperated remarks by parents a n d teachers. The c h i l d 's concern about being crazy obtrudes i n many d i fferent ways and places. Malco l m , i n associati ng to h i s figure drawing, perseverates remarks about crazi ness: " He's a crazy perso n . H e doesn't have a m ind, j ust a n ut. A n ut, that's the way he i s , he was born that way," "She's n u ts, that's what peopl e say about her H i tler was n uts, wasn't he?" Gale enters her therapist's office obviously upset, abruptly refuses to tal k of any worries, i n s i sts she's fine. Soon she tel ls of see i ng a sign i n the wai t i n g room about lectures on emotio n a l l y d isturbed c h i l ­ d ren, and s h e c r i es o u t that she's n o t crazy. B o b accidental ly cuts h i s finge r i n the occupat i o n a l therapy shop. B a d l y s h a k ing, h e stares a t the b lood and yel ls, "My God, I ' m goi ng crazy." A n other ta l ks of o n l y wanti ng Loony Tu nes comi cs: 1'Loony Tu nes," he snorts, "that's for me a l l right." Mark finds he has confused h i s c raft shop days, is afrai d that th i s means he's l o s i n g h i s m i nd . Many of the c h i ldren use h u mor about or project these concerns . . . desc r i b i ng . . . other " They often focus t h e i r crazi ness, with o r without past neu­ people as rological exams and E E G 's , upon their b ra i n /o Got no bra i n . My b ra i n is loose a n d swi m s around in my head. My bra i n and m i n d are no good, they get ti red too q u i ck," "Someti mes I get-it feel s l i ke explosions i n my head . Someth i ng l snaps up there. o . . . A considerable component of the erratic behavior of these c h i l d re n has a conscious e lement that i s, they a re "play i ng crazy." Much, though by no mea n s a l l , of the p l ay i ng crazy centers around their past experiences of and cont i n u al concerns about "being crazy." The i r p l ay i n g crazy takes many forms. I t may be very and subtle or b latant and obvious, i d entified as "pretend" by the ch i l d o r exhaustively "defended" as crazy. Some of the varied forms are: " look i n g odd," sta r i n g off i nto space, or acting utterly confused; wi l d, p r i m itive, d i sorgan i zed rage l i ke states; o d d verbal i zations, i n coherences, mutter i ngs; a l leged h a l l u ci nations and del usions; the c h i l d 's i n s i stence that he is an a n i m a l , gob l i n , or other creature; or var i o u s gross l y b izarre behaviors. Most of the c h i ldren show many of these forms of p l ay i ng cra zy. Most of the ch i l dren make c l ear though by no mea n s rel i able a n n o u n cements that they have p l ayed crazy or i ntend to do so, o r speak of " j u st prete n d i ng." The comp l ex components of the i r playing crazy often become c l ear o n l y after extended ob­ servation and therapeuti c work. At times, the c h i l d is q uite consciously, del iberatel y, a l most zestful l y play i ng crazy he i s u nder no s i g n i ficant i nter n a l pressure, is compl etely i n control , a n d a t the end i s most reassu red. Eor i f o n e can ope n l y pretend t o b e crazy, how Not o n l y cu rrent concerns but actual past i nci dents can one rea l l y be may thus be magica l ly w iped away. Perhaps more frequently, p laying crazy i s

76

T h e Soci a l I nstitution of I nsan ity used as other types of p l ay are often used, namely, to achi eve bel ated mastery of traumatic events, or a n x i ety provo k i ng i nterna l states . . . . At sti l l other t i m es agai n not when u nder m u c h pressure o r a nywhere near d i s i n tegration-the c h i l d ren pretend or toy w i th crazi n ess, in a deli berate a n d contro l led manner, as i f they were a l most experimenting with or test i n g atten­ uated psychot ic experiences: the behavi o r somehow seems d i rected toward mastery of a n t i c i pated states rather than towa rd reduction of o l d a n xieties. One feels that the c h i l d is say i n g, "What if such and-such should happen . . . ?" or "What wou l d it be l i ke i f . . ?" It m i ght wel l be labeled an " a nt i su rprise" meas­ u re, though c l ea r l y the previous psychot i c states are not total l y u n related to t h i s form o f behav i o r, i n w h i c h the c h i l d tentative l y fee l s h i s way i nto feared futu re experiences of d i s i ntegration. Fen i chel puts it well : " . . . a test act i o n : repeat­ i ng the overwhelm i n g past a n d a n t i c i pati n g the pos s i b l e future. 'Tensions are created,' . . . w h i c h m ight occu r, but at a t i m e a n d i n a degree wh ich is deter­ m i ned by the partic i pant h i m se l f, a n d w h i c h is therefore u nder contro l ." At other t i mes, when s l i pp i n g toward or v i rtual l y i n a psychotic state, the c h i l d re n may sti l l attempt in a frenzied fash ion to pretend to be crazy. O r per­ haps more accu rate l y, they pretend to be crazi e r than they are at that moment. Someti mes the c h i ld keeps a sharp eye o n his a u d i ence's reaction wh i le pro­ d u c i n g a q uite contrived, control led production of crazi n ess. He fretfu l l y awaits a response as he asks an observer to defi ne h i m . "Am I i nsane? Do you t h i n k I ' m s o i n sane, s o o u t of control that I coul d rea l l y . . . behave thi s way?" Shou l d the response b e over-so l i citous, h e may b e badly threatened by the poss i b i l ity that he is what he fear s and pretends to be. And he rnay a n g r i l y p l ead, as d i d Bart o n such occasions, ' T m not that (pp. 280-2 82; footnotes o m i tted) .

Ass u m i ng that Proposition 4 i s sou nd, what effect does early l earn i n g have on the s hared conceptions of i nsanity held in the com m u n i ty? In early c h ild­ hood, m uch fa l lacious material i s learned that i s later d iscarded when more adequ ate i nformation replaces it. Th is question leads to Proposition 5 . Proposition 5 :

The stereotypes o f insanity are continually reaffirmed, in­

advertently, in ordinary social interaction.

Although many adults become acquai nted with medical concepts of menta l i l l ness, the tradi tional stereotypes are not d i scarded but conti nue to exist alongside the medical conceptions, because the stereotypes receive al most cont i n u a l support from the mass med ia and in ord i nary soc i a l d i scou rse. I n mental health education campaign s, televised l ectures b y psych iatrists a nd others, magazi ne articles and newspaper feature stories, medical d iscussions of mental i l l ness occ ur from time to t i me. These types of d iscussio ns, how­ ever, seem to be far outnumbered by stereotypic references. A study by N un n a l l y ( 1 9 6 1 ) demonstrated that the portra i t of mental i l l­ ness in mass media i s h ighly stereotyped. In a systematic and large-scale con­ tent analysis of tel ev is ion, radio, newspapers, and magazi n es, he fou n d an image of mental d i sorder presented that was overwhelm i ngly stereotyped:

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Learning and Maintaining Role Imagery

Medi a presentati o n s emphasized the b i zarre symptoms of the menta l l y i l l . For exam p l e, i nformation relating to factor I (the concepti o n that menta l l y i l l persons look and act d i fferent from " normal" people) was recorded 8 9 times. Of these, 88 affirm the factor, that is, i nd icated or suggested that people w i th mental health problems "loo k and act d i fferent": o n l y one item denied factor 1 . I n telev i s i o n dramas, for example, the aff l icted person often enters the scene sta r i n g g lassy eyed, w i th h i s mouth w i dely m u mb l i ng i n coherent phrases or laugh i n g u n co n tro l l a b ly. Even i n what wou l d be considered the m i lder d i s orders, neurotic phobias and obsess ions, the affli cted person is presented as having b izarre faci a l expressions and actions (p. 7 4 )

Of particular i nterest a re the comparisons made between the imagery of mental disorder i n the mass media, among menta l health experts, and i n the general publ ic. I n addition to the mass med ia analysis, data were collected from a group of psyc h i atrists and psychologists and from a sample drawn from the total population. The comparisons are summarized in Figure 5 . 1 . The sol i d I i ne, representing the responses of the mental health experts, l ies

Support Disagree

I . Look a n d act d ifferent I I . W i l l power I l l . Sex d istinction I V. Avoidance of morb i d thoughts v. G u i da nce and su pport

V I . Hopelessness V I I . External causes v s . personal ity V I I I . N onseriousness IX.

function

X . Orga n i c causes

Comparison of experts, the p u b li c, a n d the mass med i a on the 1 0 i n for­ 5. 7. mation factors ( m o d i fied from N u n n a l l y 1 9 6 1 ) .

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The Social I n stitution of I nsan ity

furthest to the l eft, in the d i rection of l east stereotypy. The smal l ci rcl es-sum­ marizing the findi ngs i n the study of the mass media-l ie, for the most part, to the extreme right, the d i rection of greatest stereotypy. The broken l i ne, i n ­ dicati ng t h e fi ndi ngs of t h e sample su rvey i n t h e publ ic, l i es between t h e mass media and the experts' profi les. An i nterpretation of t h i s fi nd i ng i s that the conceptions of menta l d i sor­ der in the pub I ic a re the res u ltant of cross-pressu re: the op i n ions of experts, as expressed in menta l hea lth campaigns and "serious" mass med i a pro­ gra m m i ng, pu l l i ng p u b l i c o p i n ion away from stereotypes, but w i th the more frequent and v i s i b l e mass media productions rei nforc i ng the trad itional stereotypes. S i nce N u n nal l y's sample of the mass medi a was taken during a s i ngle time period (one week of 1 95 5 ), he makes no d i rect analysis of trends i n t i me. However, he does present some d i rect evidence that is qu ite relevant to th i s d iscussio n . H e presents t h e n umber o f telev i s i o n program s deal i ng w it h mental i l l ness and subdivi des them i nto documentary programs, which are presumably serious medical d i scussions, as contrasted with other programs; that i s, featu res and films for each year during the period 1 95 1 -1 9 5 8 . H i s fi ndi ngs are presented i n Tab le 5 . 1 . Once aga i n , we see i n the period 1 95 7-1 9 5 8 that the other features out­ n u mber the serious programs by a ratio on the order of 1 00 : 1 . Apparently, moreover, th i s di sp roportion was not decreasi ng, as many mental health workers bel ieved, but actu a l l y i ncreasi ng, as popular i n terest i n menta l d i s­ order i ncreases. Although N u n n a l l y's study represents a contri bution to our knowledge of the imagery i n the mass medi a and the general publ ic, it is somewhat l i m ited in terms of our present d i scussion, becau se the study dea l s o n l y with d i rect references to mental i l l ness and uses an i n complete set of categories for eval­ uating the references. The set of categories wi l l be d i scussed first: D i rect ref­ erences are d i scussed short ly.

Table 5. 7 .

N umber of Television Programs Deal i ng with Mental I l l ness, 1 95 1 1 958* 7 95 7-53

Documentary programs Other (featu res and fi l m s)

Documentary programs Other (features and fi l ms) •

From N u n na l l y ( 1 9 6 1 ) .

7 954

7 955

15 12

2 37

7 956

7 957

7 958

2 1 22

1 1 69

72

4 1

Learning and Maintaining Role Imagery

79

The categories that are used i n eval uati ng the content of the i magery of mental i l l ness are of u nequa l i nterest; Category 1 ("Look an d act d i fferent") and Category 6 (" hopelessness") are probably essential in u ndersta n d i n g the mental i l l n ess i magery in the general p u b l i c . There are other d i mensions, however, that are not i nc l u ded i n N un n a l l y's analys i s, the most i mportant of w h i ch are dangerousness, u npredicta b i l i ty, a nd negative eva l u ation. Thi s can be made clear by referring to newspaper coverage of mental i l l ness. In newspapers it is a common practice to mention that a rap i st o r a m u r­ derer was once a menta l patient. Here a re several examples: U nder the headl i ne "Question G i rl in C h i l d Slaying," the story beg i n s, "A 1 5-year-old girl with a h i story of menta l i l l ness is bei n g q uestioned in connection w i th a kidnap-slayi ng of a 3-year-ol d boy." A s i m i lar story u nder the head l i ne "Man K i l l ed, Two Pol icemen H u rt in Hospital Fray" begin s, "A former mental patient grabbed a pol iceman's revolver and began shooti n g at 1 5 persons i n the re­ ceiv i n g room of C i ty Hospi tal N o . 2 Thu rsday." Often acts of violence wi l l be con nected with menta l i l l ness on the bas i s o f l i ttle or no evidence. For i nstance, u nder t h e head l i ne " M i l waukee Man Goes Berserk, Shoots Officer," the story describes the events and then q uotes a po l i ce capta i n who said, "He may be a mental case." I n another story, u nder the head l i ne, "Texas Dad K i l l s Self, Four Ch i l d ren, Daughter Says," the l ast sentence of the story is "One report said Kinsey [the k i l ler] was once a mental patient." In most large newspapers, there apparently is at least one such story i n every issue. Even if the coverage of these acts of violen ce were h i g h l y accurate, it wou l d sti l l give the reader a m is l ead i ng i mp ression, because n egati ve i n ­ by positive reports. An item l i ke the fol lowi ng i s formation i s seldom a lmost i nconceivable: "Mrs. Ra lph jones, a n ex-mental pat i ent, was e lected president of the Fai rview Home a nd Garden Society at the i r meet i ng last Thu rsday." Because of h ighly b iased reporti ng, the reader i s free to make the u n war­ ranted i nference that m u rder and rape and other acts of v iolence occur more frequently among former mental patients than among the population at l arge. Actu a l l y, it has been demonstrated that the i nc i dence of crimes of v i olence (or of any c r i me) is much l ower among former mental patients than in the genera l population.3 Yet, becau se of newspaper practice, th i s is not the pi c­ t u re p resented to the publ i c . Newspapers h ave esta b l ished a n i nel uctable relationshi p between menta l i l l ness and violence. Perhaps as i mportantly, th i s connection sig nifies the i nc u rabi l i ty of menta l d i sorder; that i s, i t connects former menta l patients w i t h violent and u npred i ctab le acts. I t seems paradoxical that progress in com m u n ication tech n iques has c re­ ated a situation i n which the stereotyping process is probably grow i ng stronger. N ewspapers n ow use tel etype releases from the press associ ations; and s i n ce these associ ations report i nc idents of c rime and v iolence i nvolving mental

so

The Social I n stitution of I nsanity

patients from the entire nation, the sampl i ng b ias i n the picture presented to the publ i c is enormous. There are approx i mately 3 00,000 adu lts confined to mental hospital s in the U n i ted States on any one day, and an even larger group of former menta l pa­ tients. The newspaper practice of d a i l y report i n g the violent acts of some patient or former patient and, at the same t i me, seldom i n dicating the s ize of the vast group of nonviolent patients i s grossly m i sl ead i ng. I nadvertently, newspapers use selective report i ng of the same type that i s fou n d i n the most b l atantly false advert i sements and propaganda to conti n u a l l y "prove" that mental patients are unpred i ctably violent. The i mpact of selective reportage is great because i t confirms the p u b l i c's stereotypes of i nsan ity. Even if the newspaper were to exp l a i n the b ias i n these stories, the problem wou ld not be e l i m i nated. The vivid portrayal of a s i ngle case of h u ma n v i ol ence has more emoti onal i m pact on the reader than the statistics that i n d i cate the true actuarial risks from mental patients as a class. The average person's reaction to the fact that the probabi I i ty of the kind of violence that the newspapers report occurring is about one in a m i l l ion is usually that t hi s i s sti l l a real risk that he wi l l not accept. Yet thi s i s roughl y the r i s k o f death he u nth i n k i ngly accepts i n ta k i ng a c ross-cou ntry trip i n an a i rpl ane or automobi le. O ne component of the stereotype of i nsanity is an u n reasoned and u n reasonable fear of mental pati ents that makes the p u b l i c rel uctant t o take r i s ks i n t h i s area o f the s a m e s i ze as ri sks frequently en­ cou ntered and accepted i n the ord i nary round of l ivi ng. Reaffi rmation of the stereotype of i nsan i ty occurs not only i n the mass medi a (see Figure 5.2) but i n d i rectly in ord i na ry conversation : in jokes, in an­ ecdotes, and even i n conventional phrases. Such phrases as "Are you crazy?" " I t wou l d be a madhouse," " It's drivi ng me o u t o f my m i nd," "We were chat­ ting l i ke crazy," " H e was runn i ng l i ke mad," and l itera l ly h u ndreds of others occur frequently i n i nformal conversations. In t h i s u sage, i nsan i ty itself i s seldom the topic of conversation, and the d iscussants d o not mean to refer to the top ic of i nsan ity and are usua l l y u naware that they are doi ng so. I have overheard mental patients, when ta l ki ng among themselves, use these ph rases unth i nk i ngly. Even those mental health workers, such as psych i atrists, psychologists, and soc ial workers, who are most i nterested i n changi ng the concept of mental d i sorder often use these terms-someti mes joki ngly but usua l l y u nth i n k i ngly-i n thei r i nformal d i scussions. These terms are so m uch a part of ord i nary l anguage that o n l y the person who considers every word carefu l ly can e l i m inate them from his speech . Through verbal usage, the stereo­ type of i nsan i ty is an i nflexible part of the soc ial structu re. The i magery that is i m p l ic i t i n these p h rases should be d i scussed . When the phrase " ru n n ing l i ke mad" i s used, the i magery that th i s conveys i m p l ic­ itly i s movement of a w i l d and perhaps u ncontrol led vari ety. The question

Learning and Main taining Role Imagery

81

Examples o f visual a n d verbal i magery about mental i l l ness from news papers and magazi nes.

Figure 5.2.

"Are you out of your m i nd?" signifies a behavior of which the speaker d i sap­ proves. The frequently used term crazy often, a lthough not a lways, i m p I ies s u btle r i d i c u l e or stigma. These i m pl i cations are there even when the person u s i n g the terms does not mean the words to convey t h i s . Th i s i nadvertent a n d i nc i dental i magery i s s i m i lar t o that contained i n racial and eth n i c stereotypes. A speaker who uses the express ion "to jew someone down," may not necessar i ly be prej u d i ced aga i nst jews (as in the rural South,

The Soc i a l I nstitution of I nsan ity

82

where Jews a re rare) but s i m p l y uses the p h rase as a matter of convenience i n order to convey his meani ng; but to others the assumptions are u n mistak­ able: the i mage of the Jew as a person who is scheming and overi nterested i n money for i ts own sake. Aga i n as in raci a l and ethn i c stereotypes, imagery is someti mes conveyed through jokes and anecdotes. This exa mple of the type of joke that one hears i n i nformal conversation is taken from the Reader's Digest: ;\ visitor to a menta l hospital sees a patient who looks and acts l i ke a normal person. He asks h i m why he is i n the hos p i ta l . " B ecause I l ike potato pancakes," the patient repl ies. The visitor says, "That's not h i ng, I l ike potato pancakes my­ self." The patient turns to the v i s i to r exc itedly, "You do!" he rep l ies, "Why don't you come to my room then, l have a whole trun kfu l ! "

The impl ications that one may draw from this type o f joke are fai rly c lear. Persons who are menta l ly i l l, even when they do not seem to be, are basi ­ cally d ifferent. Th i s i s one theme, among others, that recu rs i n reference to mental i ll ness i n ordi nary conversation. Th is theme, together w i th the "looks and acts d i fferent" theme and the " i n c u rable" theme, is probably part of a s i ngle larger pattern: These dev iants ( l i ke other devia nts) belong to a fu nda­ menta l l y d i fferent c l ass of h u m a n bei ngs o r perhaps even a different species. This is a manifestation of outgroupi ng, the beliefs and actions that a re based on the premise that one's enemies, strangers, or devia nts, no matter how at­ tractive or sympathetic they may seem to the unwary, are essentia l l y different from and i nferior to one's own k i n d . Two racist jokes w i l l p rovide a n i l l ustration o f t h i s genre: ;\ black advert i s i n g executive is i n terviewed in his home, a l u xurious apa rt ment on the H udson, on the tel ev i s i o n program <� Person-to-Person." He i s i m pecca b l y dressed, a rt i c u late, a n d speaks w i th the easy, c u l t ivated accent of East Coast soci ety. He says, "Good eve n i n g Ed.<� E d M u rrow says, "Good eve n i ng, Mr. Joh nso n ." The executive i ntroduces h i s fam i l y. M urrow says, " B efore you take us on a tou r of you r home, cou l d you tel l our a u d ience somet h i ng about you r worki ng day?" Mr. Johnson says, "Certai n ly, Ed. On the typ i c a l weekday, my man comes around to p i c k me up about 9, and we get to the Aven u e about 1 0. l have an accounts conference u n t i l 1 2 , l u n ch and cocktai l s t i l l 2. At 2 an other accou nts conference u nt i l 4 , then I d ictate l etters u nti l about 6. My man p icks me up, I ' m home by 7. As often as not, we have people over for d i n ner and d r i n ks . They stay u nti I 1 1 o r 1 2, then l go out o n the balcony, a n d jes look out ober de r ibber."

A second, s lightly l ess dated variant: As the plane taxi s down the runway, the passengers of a jet hear over the i n ­ tercom: ''Good afternoon, lad ies a n d gentlemen . l am you r p i l ot." He del ivers

Lea rning and Maintaining Role Imagery

83

the usual ru ndown on the flight, ending on th i s note: " I wa nt you to know that I am the first b lack pi lot h i red by this a i rl i ne. You are in good hands ! got my bachelor's at Harvard and my master's at MIT, graduating from both school s w ith honors. I have been through t h e same long rigorous tra i n i ng as a l l t h e white pi lots, and received an award for being fi rst i n my c lass. I wou ld l i ke to tel l you more, but right now I got to get this big motherfucker off the gro u n d ! "

These two jokes, and l i tera l l y h u nd reds of other s i m i l ar ones, a l l make ex­ actly the same poi nt: no matter how advanced the member of the outgroup m ight seem, fu ndamenta l ly they are d ifferent. To su mmarize this section: p u b l i c stereotypes of mental i l l ness are diffi­ c u l t to change because they receive conti nual al though i nadvertent su pport from the mass media and in ord i nary conversation. I n support of this propo­ sition, evi dence from several stu d ies and the author's observations have been cited. On the basi s of this evidence, one wou ld suspect that menta l health cam­ paigns that are based l argely on d i ssem i nati ng i nformation wi l l be doomed to fa i l u re beca use of the overwhel m i ng preponderance of stereotyped i nfor­ mation and i magery to which the average person is exposed. It i s d i ffi cul t to say at this t i me how the situation cou l d be changed. I n some med ia-telev i sion, for example-a defin i te attempt is made to "clean up" the references to mental i l l ness. As N u nn a l l y ( 1 9 6 1 ) poi nts out, however, these attempts are not particu larly s uccessfu l . W h i l e television has man aged to e l i m i nate v i rtually a l l the i rreverent slang references to menta l i l l ness such as "goofbal l," "fl i pped," "n ut," and "loony," there has been no attempt to change the visual i magery. Why are these stereotypes res i stant to change? One possible explanation is that they are functional for the cu rrent soc ia l order and tend to be i nte­ grated i nto the psychological makeup of al l members of the society. Raci al stereotypes may perform s i m i lar fu nctions. I n the southern part o f t h e U n ited States, for example, racia l stereotypes are not fortuitous and isolated attitudes; rather, they are i ntegral parts of the southerner's cogn itive structure. The stereo­ type of the bl ack fu l fi l ls the functions of a contrast conception, a reference poi nt for making soci a l comparisons and self-eval uations. One cl u e to the existence of contrast conceptions is a h ig hly p ro l iferated vocabulary of ver­ nac u l a r terms, such as exi sts in the South for referral to bl acks. "J ig," "coon," "spade," "buck," and "j u ngle b u n ny" are only a few of an enormous n u mber of such terms. In cu rrent vernac u l a r, there i s an eq ua lly large n um ber of terms for referring to i nsan i ty, or goi ng i nsane, for example: "out of one's m i nd," " l o s i n g one's m i nd," "the m i n d snappi ng," "out of one's head," "wrong i n the head," "not right i n the head" (or a gestu re i n which one moves the fin­ ger in a c i rcle wh i l e po i ntin g to one's head), "teched in the head," "cracked," " loony," "off one's rocker," "off the deep end," " n uts," "bughouse," "fl i pped,"

84

The Social I n stitution of I nsanity

''psycho," "goofy," " " lose you r marbles," "bats i n the belfry" (or j ust "batty"), "screwy" or "screwbal l," "crazy," "deranged," "demented." judging from the frequency with which references to mental d i sorder ap­ pear in the mass medi a and in co l loqui a l speech, the concept of menta l d i s­ order serves as a fundamental contrast conception i n o u r society, functioni ng to preserve the c urrent mores. The d i splacement of such a convenient con­ cept is probabl y resisted for t h i s reason . In some p re l iterate societies, the concept of spirit possession "expla ins" d reams, sickness, mental d isorder, great success, u ntimely death, and many otherwise u nexplainable phenomena. The average member of such a society has, therefore, a substantial psychological investment i n the bel ief i n spi rit possessio n . S i m i larly, i n the U nited States, t he average c itizen res i sts changes i n h i s concept of i nsan i ty�or, if h e i s i n the m iddle c l ass, h i s concept o f mental d isease�because concepts are functional for m a i n ta i n i ng h i s cus­ tomary moral and cogni tive world . Th i s section concludes w it h a d iscussion of a process that may relate stereo­ typi n g of the menta l l y i l l to the soc i a l dynam ics of menta l i l l ness: vicarious l ea r n i ng. The tra n s m i ss i o n of stereotyped i magery in the mass medi a and o rd i na ry conversation may th row l ight on a question that has been hotly debated; whether the symptoms of menta l d isorder are i n herent or l earned. Although advocates of the learning po i n t of view have poi nted to i nstances where symptoms seemed to be l earned (folie a deux, role models in the fam­ i ly), they have never been com pletely satisfied with t h i s exp lanation, s i nce i t p laces s o much emphasis o n what seem t o b e i n frequent occu rrences. The d iscussion here that everyone i n a society learns the symptoms of menta l d i sorder vicariou s l y t h rough the i magery that is u n i ntentiona l l y conveyed i n everyday l i fe. Th i s i magery tends t o b e t i ed t o t h e vernac u l a r of each l anguage and c u lt ure; t h i s assoc i ation may be one reason why there are considerabl e var i ations i n the symptoms of menta l d i sorder that occu r i n d i fferent cul tu res. I ( a s suggested here, t h is i magery i s ava i lable to the ru le­ breaker to structu re and thus to " u nderstand" h is own experience, the qu al ­ i ty of the societal reaction becomes extremely i mportan t i n determi ni ng the d u ration and outcome of the i n i t i a l l y amorphous and u nstructu red resi du al rule-breaki ng. T he nature o f the societal reaction i s s hown i n t h e next section to be made u p of a l ternative, i n deed, m utua l ly exc l u sive components: n o r­ m a l i zation o r l abel i ng.

NORMALIZATION A N D lAB E L I N G

Accardi ng to the analysis presented here, the traditional stereotypes of men­ tal d i sorder are so l id l y entrenched in the pop ulation because they a re lea rned early in c h i l d hood and a re conti n uously reaffi rmed in the mass medi a and i n

Normalization and Labeling

85

everyday conversation. How do these bel iefs function in the processes lead­ i ng to mental d i sorder? Th i s question is consi dered fi rst by referring to the earl ier d i scussion of the societal reaction to residual rule-breaki ng. It was stated that the usual reaction to residual ru le-breaking is normal­ i zation and that in these cases most ru l e-breaking i s transitory. The societal reaction to ru le-breaki ng i s not always normal ization, however. I n a sma l l pro­ portion of cases, the reaction goes the other way, exaggerati ng and at t i mes d i storti ng the extent and degree of the violation. Thi s pattern or exaggeration, which we w i l l cal l " l abe l i ng," has been noted by Ga rfi n kel ( 1 9 5 6) in h i s d i scussion o f the "degradation" of offi c i a l l y recog n i zed c r i m i nals. Coffman ( 1 9 5 9 ) makes a s i m i l ar point in h i s description of the "di screditi ng" of men­ tal patients: \The patient's case record] i s apparently not regu larly used to record occa sions when the patient showed capacity to cope honorably and effectively with d ifficult l i fe situations. Nor is the case record typi ca l ly used to provide a rough average of sam p l i n g of h i s past conduct. [Rather, it extracts] from h i s whole l ife cou rse a l ist of those i n cidents that have or m ight have had "symptomatic" sig I th i n k that most of the i nformation gathered i n case records is n ificance . qu ite true, although it m ight seem also to be true that almost anyone's l ife course cou ld yield up enough den igrati ng facts to provide grounds for the record's j us tification of com m itment. .

.

.

Apparently under some cond itions, the societal reaction to ru le-break i ng i s to seek out si gns of abnorma l i ty i n the deviant's h istory to show that he was always essentia l l y a deviant. The contrasti ng socia l reactions of normal i zation and labe l i ng provides a means of answering two fu n damental questions. Fi rst, if ru le-breaking ari ses from d iverse sou rces-physical, psychological, and s i tuational how does the u n iform ity of behavior that is associated with i nsan i ty develop? Second, if ru le-breaking i s usual ly transitory, how does it become stab i l i zed in those patients who become chron ically deviant? To summarize, what are the sources of u niform i ty and sta b i l i ty of deviant behavi or? In the approach taken here, the answer to t h i s question i s based on Propo­ sitions 4 and 5, that the role i magery of i n sa n ity is learned early in ch i l dhood and is reaffi rmed i n soc ia l i nteraction. I n a crisis, when the deviance of an i nd ividual becomes a p u b l i c i ssue, the traditional stereotype of i nsan ity be­ comes the g u i d i ng i magery for action, both for those reacti ng to the deviant and, at ti m es, for the deviant h i mself. When societa l agents and persons arou nd the deviant react to him u n iformly i n terms of the trad itional stereo­ types of i nsan i ty, h i s amorphous and u nstructu red ru le-brea k i n g tends to crysta l l i ze i n conform i ty to these expectations, thus becom i ng s i m i lar to the behavior of other deviants c l assified as menta l l y i l l, and stable over time. The process of becom i ng u n iform and stable is completed when the trad itional

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The Soc ial Institution of I nsan ity

i magery becomes a part of the devia nt's ori entation for g u i d i ng h i s own behavior. The i dea that cu ltural stereotypes may stabi l ize res idual rule-breaking and tend to produce u n iformity in symptoms i s supported by cross-cu ltural stud­ i es of mental disorder. Although some observers i ns i st there are u nderl y i ng s i m i larities, many agree that there are enormous di fferences i n the manifest symptoms of stable mental d i sorder between societies and great s i m i l arity within societies (Yap 1 95 1 ) . These considerations suggest that t he label ing process i s a crucia l conti n­ gency i n most careers of resi dual deviance. Th us G lass ( 1 95 3 ), who observed that neuropsych iatric causal ities may not become menta l l y i l l if they are kept w ith the i r u nit, goes on to say that m i l itary experience with psychotherapy has been d i sappoi nti ng. So ldiers who are removed from their u n i t to a hospita l , h e states, often go on t o become chron ica l l y i mpa i red . That i s , their deviance i s stabi l i zed by the label i ng process, which i s i m p l i ci t i n the i r removal and hospita l i zatio n . A s i m i lar i nterpretation can be made by compari ng the ob­ servations of ch i l d hood d isorders among Mexican-Americans with those of Anglo c h i l d re n . C h i ldhood d isorders such as susto (an i l l ness bel ieved to re­ s u l t from fright) someti mes have damagi ng outcomes i n Mexican-American ch i l dren (Saunders 1 954, p . 1 42 ) . Yet the deviant behavior i nvo lved i s very s i m i l ar to that which seems to have h igh i n c i dence among Anglo ch i ldren, with permanent i mpai rment v i rtu a l ly never occu rring. Apparently th rough cues from h i s elders, the Mexican-American ch i l d, behaving i n itial l y m uch l i ke h i s Anglo counterpart, learns to enter the sick role, at ti mes with serious consequences.4

ACCEPTANCE OF THE DEVIANT ROLE

From this point of view, most mental d i sorder can be considered to be a social role. Th i s social role complements and reflects the status of the i nsane in the soc i al structu re. I t is through the soc ia l processes that mai nta i n the sta­ tus of the i nsane that the varied rule-breaking from which mental d isorder arises is made u n iform and stable. The stabi l i zation and u n iform i zation of residual devi ance are completed when the deviant accepts the role of the i n­ sane as the framework with i n which he organ i zes h i s own behavior. The th ree propositions stated below suggest some of the processes that cause the de­ viant to accept such a stigmatized role. Proposition 6:

Labeled devian ts may be rewarded for playing the s tereo

typed devian t role.

O rdi nari ly patients who d i splay " i nsigh t" are rewarded by psych iatrists and other personnel . That is, patients who manage to fi nd ev i dence of "their i l l-

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87

ness" i n the i r past and present behavior, confi r m i ng the medical and socie­ tal d i agnosi s, receive benefits. Th i s pattern of behavior i s a spec i a l case of a more general pattern that has been called the "aposto l i c function" by Ba l i nt ( 1 95 7), i n which the physician and others i nadvertently cause the patient to d i sp lay symptoms of the i l l ness the physician th i nks the patient has. The apos­ tol i c function occurs in the context of bargai n i ng between the patient and the doctor over what s h a l l be deci ded to be the nature of the patient's i l l ness: Some of the people who, for some reason or other, find it d ifficult to cope w ith problems of thei r I ives resort to becoming i I I . If the doctor has the oppor tun ity of see i ng them in the fi rst phases of their being i l l , i .e., before they settle down to a defi nite "organized" i l l ness, he may observe that these patients, so to speak, offer or propose various i l l nesses, and that they have to go on offeri ng new i l l nesses until between doctor and patient an agreement can be reached resulting in the acceptance by both of them of one of the i l l nesses as j ustified. (p. 1 8)

I t i s i n this flu i d situation that B a l i nt bel ieves the doctor i nfl uences the man­ ifestations of i l l ness: Aposto l i c m ission or function means in the first pl ace that every doctor has a vague, but almost u nshakably firm, idea of how a patient ought to behave when i l l . Although t h i s idea i s anyt h i n g but exp l i c i t and concrete, it is i m mensely powerfu l, a n d i nfluences, as w e have found, practica l l y every deta i l o f the doctor's work with h i s patients. I t was al most a s if every doctor had re vealed knowledge of what was right and what was wrong for patients to expect and to endure, and further, as if he had a sacred duty to convert to h i s faith a l l t h e ignorant a n d unbe l i ev i ng among h i s patients. ( p . 2 1 6)

N ot only physicians but a lso other hospital personnel and even other pa­ tients reward the deviant for conformi ng to the stereotypes. Caudi l l , Redl ich, G i l more, and B rody ( 1 9 5 2 ), who made observations of ward l ife in the guise of Cau d i l l being a patient, reports various pressures from fel l ow patients. I n the fol lowi ng excerpt, for example, there i s the suggestion i n the advice of the other patients that he should rea l i ze that he i s a s i ck m a n : O n t h e second day, fol lowing a conference with h i s therapist, t h e observer expressed resentment over not havi ng goi ng out priv i l eges to visit the l i brary and work on h i s book h i s compu l sive concern over h i s i na b i l ity to fi n ish this task being (accord ing to h i s s i m u l ated case h istory) one of the factors lead ing to h i s hospita l i zation. I m med i ately two patients, Mr. H i l l and Mrs. Lewis, who were l ater to become h i s closest friends, to ld him he was being "defensive"; si nce h i s doctor d i d not wish h i m to do such work, it was probably better "to l ay off it." Mr. H i l l went on to say that one of h i s troub les when he first came to the hospital was th i n king of thi ngs that he had to do or thought he had to do. He said that now he did not bother about anyth ing. Mrs. Lewi s said that at first

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The Soc i a l I nstitution of I nsan i ty she had treated the hospital as a sort of hotel and had spent her therapeutic hours "charmi ng" her doctor, but i t had been poi n ted out to her by others that work with her doctor i f t h i s was a mental hospital and t h a t she s h o u l d she expected to g e t wel l . ( p . 3 1 4 344)

I n the Ca l iforn i a mental h ospita l i n which the author conducted a study i n 1 959, a common theme i n the d i scussions between patients on the ad­ m issions wards was the " recogn ition" of one's i l l ness. Thi s i nterchange, which took p l ace during a ward meet i ng on a female ad m i ss i on ward, provides an extreme example: New Patient:

Another Patient: Another Patient: New Patient: First Patient:

I don't belong here. I don't l i ke a l l these crazy people. W h e n c a n I ta l k t o the doctor? I 've been here f o u r days a n d I haven't seen the doctor. I ' m not crazy. She says she's not crazy. (Laughter from pati ents.) Hon ey, what I'd l i ke to know is, if you're not crazy, how d i d you you r ass i n t h i s hospita l ? It's com p l icated, but I can exp l a i n . That's what they a l l say. (General

Thus there is considerab le p ressure on the patient to accept the role of the menta l l y i l l as part of their self-conception. Proposition 7 :

Labeled deviants are punished when they a ttempt the re­

turn to conventional roles.

The second p rocess operative is the systematic blockage of entry to nonde­ v i ant roles once the label has been publicly appl ied. 5 Thus the former mental patient, a lthough he i s u rged to rehabi l itate h i mself i n the com m u n ity, usu­ ally finds h i mself d i scri m i n ated agai nst i n seeki ng to ret u rn to h is old status and on try i ng to fi nd a new one in the occupational, marital, soc i a l , and other spheres. Stud ies have shown that former menta l patients, l i ke ex-convicts, may find i t d iffi c u l t to find employment, even when their behavior and q u a l i fications a re u nexceptionable. I n an exper imental study, Phi l l i ps ( 1 963) has shown that the reject ion of the menta l l y i I I i s largely a matter of stigmatization, rather than an eva luation of thei r behavior: Despite the fact that t h e " normal" person i s more an " ideal type" t h a n a nor mal person, when he i s descri bed as hav i n g been in a mental hospital he is re j ected more t h a n psychotic i n d iv i d u a l s described as not see k i n g h e l p or as see i n g a clergyman, and more than a depressed neuroti c a c l ergy m a n . Even when the n o r m a l person is described as [ o n l y ! see i ng a psyc h i atrist, he i s rejected more than a s i m p l e schi zophren ic who seeks n o help, [and! more t h a n

Acceptance of the Deviant Role

89

a phobic compul sive i ndividual seeki ng no help or seeing a clergyman or physician. (pp. 963 9 7 3 )

Propositions 6 and 7, taken together, suggest that to a degree the labeled deviant is rewarded for deviating and p u n is hed for attempt i n g to conform. Proposition 8: In the crisis occurring when a residual rule breaker is pub licly labeled, the devian t is highly suggestible and may accept the proffered role of the insane as the only alternative.

When gross ru le-breaking is p u b l i c l y recogn i zed an d made an issue, the rule-breaker may be profoundly confused, anxi ous, and ashamed. In t h i s cri­ sis, i t seems reasonable to assume that the r u l e-breaker w i l l be suggesti b l e t o the cues t h a t he gets from the reactions o f others toward h i m . 6 B u t those arou n d h i m are a l so in a crisis: the i ncomprehensible nature of the ru le­ b reaking and the see m i ng need for i mmed i ate action lead them to take col­ lective action agai nst the rule-breaker on the basis of the attitude which a l l share the trad itional stereotypes o f i n san i ty. The rule-breaker i s sensitive to the cues provided by these others and beg i n s to t h i n k of h i mself i n terms of the stereotyped rol e of i nsan i ty, which is part of h i s own rol e vocabu lary al so, s i nce he-l i ke those reacti ng to h i m-learned it early in ch i ldhood . I n th i s s i tuation, h i s behavior may beg i n to fol low the pattern suggested by h i s own stereotypes and the reactions of others. That is, when a res i du al rule­ b reaker orga n i zes h i s behavior w ith i n the framework of menta l d i sorder, and when his organ i zation i s val i dated by others, particularly prestigeful others such as physi ci ans, he i s " hooked" and w i l l proceed on a career of chro n i c devi ance. There is l ittle d i rect ev i dence fo r the part p layed by ro le i mages in the development of mental i l l ness, but there are various suggestions that i t may be an i mportant one. For examp le, Rogier and Ho l l i ngshead ( 1 965 ), i n their study of sch i zophren ia in Puerto R ico, give considerable emphasi s to the role of the loco ( l u natic) in the cases they studied. Comparing the 40 persons di ­ agnosed as sch i zophren ic w it h t h e control group, they state: The rol e of the loco presents a problem to nearly a l l schizophren ic persons but to only a few who are free of the i l l ness. Sick persons are extraord i narily defensive about the topic of the loco. Ti me and again, they state that they are not locos when no such question is being asked. When asked d i rectly, only one sick person states that he is a loco; only one spouse of a sick person asserts th i s o f h i s mate. The remai n i ng persons i n the s i c k group d o not a d m i t t o locura. Rather, after a forcefu l den ial, they add such ph rases as: "Someti mes I act l i ke one, but I a m not one." "I may eventu a l l y become one, but I a m not one now." " I f I don't get help, I may become loco." " Perhaps I am on the road to becom i ng one." "Only at ti mes do I act l i ke a loco." (p. 2 2 1 )

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The Social I nstitution of I nsan ity

Although a l l but two of the 40 persons d iagnosed as sch i zophren i c den ied bein g l oco i n response to d i rect questions, the fact that they themselves rai sed the issue when the question was not as ked suggests that the role i mage of the loco was being u sed i n their own thought processes, regardless of thei r ex­ pl icit den i a l . It is i m portant for the reader to u n derstand that the d i agnosis of sch i zophre ni a was made as part of the research process in this study and not necessar i l y offi ci al ly in the com m u n i ty. The su bj ects were persons who had sought psychiatric help, and who were d iagnosed as sch i zophren i c by a psy­ ch iatrist attached to the research group. From the poi nt of view presented here, we may consider the "si ck" ( i .e., sch izophren i c) group as persons who are experimenting with the ro le of the menta l l y i l l . Rogier and Hol l i ngshead ( 1 965) a l so fou n d that the ro le i mage of the loco held by the "sick" group was not d ifferent from that held by the rest of the com m u n ity: Sch izophrenic persons are particularly vul nerable to being assigned the role of the loco. Consequently, we explored the poss i b i l ity that the sch i zophrenic's portrayal of this role wou ld be d rawn in less harsh and more ben ign terms than that d rawn by wel l peop le. This i dea was erroneous! There i s no tendency on the part of the sch i zophrenics to soften the portra it of the loco; sick and wel l persons desc ribe h i m as violent, i m mora l , c ri m i n a l , f i lthy, i d i osyncratic, and worth less. Moreover, men a n d women do not d i ffer i n their conceptions of the loco. The i r views are u n i form and deep; perhaps they are fixed una lterably. \p. 2 1 8)

Thi s fin d i n g i s i n accord with Propositions 4 and 5 : if deviant role i m agery is learned early and contin ua l l y reaffirmed, a person's i mage of i nsan ity wou l d not l i kely b e affected even when h e h i mself r u n s t h e risk o f being labeled. The rol e i mages are i ntegral parts of the soc i a l structure an d therefore n ot easi l y re l i nqu ished. H o ld ing these relatively fixed i mages, the rule-breaker, l i ke those around h i m, is susceptible to social suggestion i n a crisis. The role of suggestion i s noted by Warner ( 1 958) i n h is descr i ption of bone-po i nting magic: The effect of [the suggestion of the ent i re com m u n ity on the victim] i s ob viously drastic. An analogous situation in our society is hard to i magine. If a l l a man's near k i n , his father, mother, brothers a n d sisters, wife, c h i l d ren, busi ness associates, friends, and all the other members of the society, should sud denly w ithdraw themselves because of some dramatic c ircumstance, refusing to take any attitude but one of taboo . . . and then perform over him a sacred ceremony . . . the enormous suggestive power of this movement . . . of the com m u n ity after it has had its attitudes [toward the victim] crystal l i zed can be some what understood by ourselves. (p. 242)

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91

I f we su bstitute for b lack magic the taboo that u s ua l l y accompan ies men­ tal d i sorder and consi der a com m i tment proceedi n g or even mental hospi ­ t a l a d m i ssi on a s a sacred ceremony, t h e s i m i l arity between Wa rner's de­ scription and the typical events in the development of menta l d isorder i s cons i derable. The last th ree propositions suggest that once a person has been pl aced i n a devi ant status, there are rewards for conform i ng t o the dev i an t role and p u n ish ment for not conform i ng to the deviant role. Th i s is not to i mply, how­ ever, that the symptomatic behavior of persons occupy i ng a deviant status i s always a manifestation of conform i n g behavior. To exp lai n th i s po i n t, some d i scussion of the process of self-control in "normals" is necessary. I n a d i scussion of the process of self-control , S h ibutani ( 1 9 59, Chapter 6) notes that self-control is not automatic but i s an i ntricate and del i cately bal­ anced process, susta i nable only u nder propitious c i rcu mstances. He poi nts out that fatigue, the reaction to narcotics, excessive excitement or tension (such as i s generated in mobs), or a n umber of other cond itions i nterfere with self­ control; conversely, conditions that produce normal bod i ly states, and del i b­ erative processes, such as symbo l i zation a nd i magi native rehearsa l before action, faci I i tate it. One may argue that a crucially i m portant aspect of i magi native rehearsal is the i mage of h i mself that the actor projects i nto h is futu re action . Certa i n ly i n American soci ety, the c u ltural i mage of the "normal" adu l t i s that of a person endowed with self-control ("wi l l power," "backbone," or "strength of character") . For the person who sees h i mself as endowed with the trait of self­ control, self-control is faci l itated, since he can i magi ne h i mself enduring stress d u ri ng h i s i magi native rehearsal and a l so w h i l e u nder actu al stress. For a person who has acq u i red an i mage of h i mself as lack i ng the abi l i ty to control h i s own actions, the process of self-control i s l i kely to break down u n der stress. Such a person may feel that he has reached h i s "breaki ng-poi nt" u nder c i rcumstances that wou l d be endured by a person with a "normal" self­ conception. Th i s is to say, a greater lack of self-control than can be exp lai ned by stress tends to appear i n those roles for which the c u lture tra n s m i ts i m ­ agery that emphasizes lack o f self-contro l . I n American soci ety, s u c h i magery i s trans m i tted for the roles of the very young and very old, drunkards and drug addicts, gamblers, and the mentally i l l . Thus, the social role o f the mentally i l l has a different significance a t differ­ ent phases of residual deviance. When label i ng fi rst occurs, it merely gives a name to rule-breaki ng, which has other roots. When (and if) the ru le-breaki ng becomes an i ssue and i s not ignored or rationalized away, label ing may create a soc i a l type, a pattern of "symptomatic" behavior i n conform i ty with the stereotyped expectati ons of others. Fi nal ly, to the extent that the deviant role becomes a part of the deviant's self-conception, his abi l i ty to control his own

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The Soci a l I n stitution of I nsan ity

behavior may be i mpai red unde r stress, res u lting i n episodes of comp u l s ive behavior. The precedi ng e i gh t hypotheses form the basis for the fi n a l causal hy­ pothesi s. Pro p osition 9: Among residual rule-breakers, labeling is among the most important causes or careers or residua l devia n ce.

Thi s proposition assu mes that most resi d u a l ru l e-breaki ng, if i t does not come the basis for entry i nto the s i ck role, w i l l not l ead to a deviant career. The most u s u a l case, accord i ng to the arg ument that has been advanced here, is that t here wi l l be few i f any soci a l consequences of resi d u a l r u l e­ b reaki ng. Occasiona l l y, however, such r u l e-brea k i n g may become the basi s for major in the rule-breaker's soc i a l status, other than demotion to the status of a menta l patient. The three excerpts that fol low i l l ustrate such s h i fts. CASE 1 : Some of the I ndian tri bes of Californ ia accorded prestige princi pal l y to those who passed th rough certai n trance experiences. Not all of these tribes bel i eved that i t was exc l usively women who were so blessed, but among the Shasta th is was the conve ntion. Thei r shamans were women, and they were accorded the prestige in the com m u n i ty. They were chosen because of their constitutional l iabi l ity to trance and a l l ied manifestations. One day the woman who was so desti ned, w h i l e she was about her usual work, fel l sud­ denly to the gro u n d . She h ad heard a voice speaking to her in tones of the i ntensity. Turni ng, she had seen a man with drawn bow a n d arrow. He commanded her to s i ng on p a i n of being shot th rough the heart by h i s arrow, but u nder the stress of the experience she fel l senseless. l ler fam i l y gathered. She was rigidly, hard ly breathi ng. They knew that for some time she had had d reams special character which indicated a shama n i stic cal l i ng, dreams fa l l i n g off c l i ffs or trees, or of being s urrounded of escaping grizzly swarms of yel low jackets. The commu n ity knew therefore what to expect. After a few hours the woman began to moan gently and to rol l about upon the trembl ing She was s upposed to be repeati n g the song which been tol d to s i ng and which d u ri n g the trance had been taught her the spi rit i tself, and immediatel y' b lood oozed from her mouth. When the woman had come to hersel f after the first encounter with her spi rit, she danced that n ight her first i n i tiatory shaman's dance. For three n i ghts she danced, holding herself by a rope that was swung from the On the thi rd n ight she had to receive i n her body her power from the spi rit. She was dancing, and as she felt the approach of the moment she cal led out, "He w i l l shoot m e , he w i l l shoot me," Her friends stood c lose, for when she reeled i n a kind of cata leptic seizure, they had to seize her before she fel l or she wou l d die . . . . From th i s time on s h e contin ued to val idate her supernatura l power by further cata leptic demonstrations, and she was cal led upon i n great emergen

Acceptance of the Devian t Role

93

c ies of l i fe a n d death, for c u r i n g and for d i v ination a n d for counsel. She became i n other words, by t h i s procedure a wom a n of great power a n d i m portance. (Be nedict 1 946, pp. 243 2 47) CASE 2 : [Samuel l ived i n the house of E l i , the p r i est O n e n ight as Samuel lay down, h e h eard a voi ce cal l h i s name] . . . and h e a n swered, " Here a m 1 ." And h e ran to E l i, and said, " Here am I; for t h o u cal lest me." And h e said, " I called not; l i e down aga i n ." A n d h e went a n d l a y dow n . [Agai n Samuel heard h i s n a m e cal led] . . . and Samuel arose and went to E l i , and " H e re am I; for thou d idst cal l me." And h e a n swered, "I cal led not, my son; l ie down agai n ." [For the t h i rd ti me, Samuel heard his name called ] . . . . And h e arose and went to E l i . and said, " Here am I, for thou d iclst ca l l me." And E l i perceived that the Lord had cal led the c h i ld. Therefore Eli said u n to Samuel, " Go, lie dow n : and it shall be, i f l l e cal l thee, that you s h a l l say, Speak, Lord, for thy servant heareth." So Sam uel went a n d l a y down i n h i s place. And t h e Lord came, and stood, a n d cal led as at other t imes, " Samuel, Samu e l ." Then Samuel answered, "Speak, Lord, for thy serva n t heareth." [Samuel hears prophesied the downfa l l of the house of E l i ] . . . . ;\nd all I s rael from D a n even to Beersheba knew t h at Samuel was establ i s hed to be a prophet of the Lord. ( I Sam. 3 :4 6, 8 1 0, 20) CASE 3 : I NTERV I EWER: "How d i d you fi rst come to bel i eve that you had psych i c powers, Mrs. Bencl i t:" " . . . d u r i n g this part i c u l a r period of my l i fe, I a n um ber of personal prob lems that seemed overwhe l m i ng to me was at the ti me. I was thoroughly depressed a n d confused, and I felt that the stra i n was gett i ng progressively worse. I had been i n t h i s state for abut two weeks, when one S u n d ay m o r n i ng, i n c h u rch, I was shocked to see, up in the rafters of the cei l i ng of the ch urch, a group of a nge ls. I cou ldn't keep my eyes from the s ight a l though I noticed that no one else in the congregation was looki n g up. After t h i s experience, I wan d e red around for several days, hard l y k nowi n g what to do w i t h myself. One eve n i ng soon after, I went to a receptio n , hop i n g to take my m i nd from my troubles." " I stayed pretty much to myself a t t h e party, b u t I soon noticed, that across the room t here was a woman who was watch i n g me i n tently. She fi n a l ly came over to me and i n troduced herself. She then expl a ined c l a i rvoyance to me at some length. I told her about my vision in the c h u rch, She exp l a ined that t h i s experience was a n exa m p l e of my psyc h i c powers. S h e said t h a t she was a psy­ c hi c, and that she c o u l d tel l that I had the gift a lso. Although her explanation to me, I felt somewhat rel i eved . I n the ensu i ng weeks, I saw sounded her often a n d we often had l engthy conversations. She i n troduced me i nto the group of c l a i rvoyants and i n terested persons that she belonged to . . . . I t was to t h i s group that I f irst began to demonstrate my c l a i rvoyance . . . . Several years after t h i s I was able to arrange, with t he h e l p of my h usband [ her husband is a phys i c i an 1 an appearance before the Royal Academy of Med i c i n e for a demon stration of c l a i rvoya nce."8

Cases 1 and 2 i l l ustrate elevations in soc i a l status that a re based on pri­ mary ru le-breaki ng. Case 3 i l l ustrates what may be ca l led a lateral movement

94

The Social I nstitution of I nsanity

i n status, si nce Mrs. Bend it has obviously become com pletely i denti fied with her role as a clai rvoyant. The l i ke l i hood that res i d ual ru le-breaking in i tself w i l l not l ead to l abel in g as a deviant d raws attention to the central sign ificance o f t h e contingencies that i n fl uence the d i rection and i ntensity of the soc i etal reaction. One of the u rgent conceptua l tasks for a soc i ological theory of deviant behav i or i s t h e development o f a p recise a n d w i dely appl icable set o f such conti ngen­ cies. The classifi catio n that is offered here is o n l y a crude fi rst step in t h i s d i rection. A l th ough a w i de variety of contingencies l ead to l abel i ng, they can be s i m p l y c lassi fied i n terms of the nature of the rule-breaki ng, the person who breaks the rules, and the com m u n i ty i n which the rule-brea king occurs. Other things bei ng equal, the severity of the soci etal reaction is a function of, first, the degree, amount, a nd v i s i b i l i ty of the ru le-breaki n g; secon d, the power of the r u l e-breaker a nd the soc i a l d istance between h i m an d the agents of social contro l ; and fi n a l l y, the tolerance level of the com m u n i ty an d the ava i l ­ abil ity i n t h e cu lture of t h e comm u nity o f a lternative n ondeviant roles.9 Par­ ticularly crucial for fut ure research is the i mportance of the fi rst two contin­ gencies (the amount and degree of r u l e-breaking), which are characteristics of the ru le-breaker, relative to the rema i n i ng five contingencies, which are characteristics of the social system. To the extent that these five factors are found empirica l l y to be i ndependent determ i nants of labe l i ng and den ial , the status of the menta l patient can be considered a partly ascri bed rather than a completely achi eved status. The dynamics of treated mental i l l ness cou l d then be profitably stu di ed qu ite apart from the i ndividual dynam ics o f men­ tal d i sorder by focu si ng on social systemic conti ngencies.

A NOTE O N F E E D BACK I N D EVIANCE-AM P L I F Y I N G SYSTEMS

It should be noted, h owever, that t hese contin gencies are causal o n l y be­ cause they become part of a dynam i c system: the reci procal an d c u m u l ative i nterrelation between the rule-breaker's behavior and the social reaction . 10 For example, the more the r u l e-breaker enters the rol e o f the menta l l y i l l , the more h e is defined by others as mentally i l l ; but the more h e is defined as menta l l y i l l , the more ful l y he enters the role, and so on . Th is k i nd of vicious c i rc l e i s qu i te characteristic of many different k i nds of social an d i n d ividual systems. I t i s very i mportant to u nderstand the part that social conti ngencies p l ay i n such a system, s i n ce the cause-effect relationship is not a sim pl e one. In the Rogier and H o l l i ngshead ( 1 965) study of sch i zophre n i a in Puerto R ico, the authors drew attention to the dynamic i nterrelation between role entry and changes in the deviant's self-conception:

A Note on Feedback in Deviance-Amplifying Systems

95

Although the sick person is deeply absorbed in h i s i l l n ess and yearns to speak about it, confidants a re carefu l ly selected. The i l l ness i s suppressed as a topic of conversation with friends and associates. Efforts are made to pretend that he is not a loco. He controls activities that exacerbate h i s loco l i ke be havior. These efforts are rel atively futi le, however, as the symptoms of the i l l­ ness are strong and rea d i l y visible i n the crowded social setting i n which he l ives . In poi nt of fact, the sick person has begu n to be v iewed and treated as a loco. He w ithdraws from soci ety out of fear that he w i l l be stigmatized as a loco. I n turn, the rejection by h i s friends and associ ates pushes h i m to with draw. The stigma attached to th i s role is so strong that the withdrawa l of the sick person from partici pation i n all types of soc i a l groups appears to be a natura l sequel t o t h e condemnation he suffers. (pp. 2 4 1 2 4 2 )

The process described i n th i s passage can be i nterpreted as a vicious c i rcle begun by stigmatization, withdrawal to avo id more stigma, stigmatization be­ cause of w i thdrawal or i ts effects, and so on around the c i rcle. The vicious c i rcle effect occu rs not only in the entrance to role-play i ng by the ru le-breaker but i n other parts of the system al so. I n order to see th i s more clearly, i t i s u sefu l to represent the theory as a flowchart (Figure 5 .3 ) . 1 1 Th i s chart makes i t clear that the theory of stable menta l d i sorder d i scussed here is actu a l l y an assembly of system modu les that i nteract. There is the mod u le of residual ru le-breaki ng; the conti ngency mod u l e, which f i lters out most of the rule-breakers through denial; the cris i s modu l e; the rule-breaker's self-conception mod u l e; the soc ia l control mod u l e, which operates such that the deviant tends to p l ay the stereotyped deviant rol e; and final ly, the com­ p u l sive behavior mod u le. Each of these mod u les is a system in itself with i ts own conti ngencies. I n the context of the larger theory, however, each is a subsystem, which u nder proper cond itions, operates as part of the entire network. The total system forms what Maruyama has cal led a "devi ation-ampl ify i ng system," i n whi ch low-probab i l ity events a re stab i l i zed. I n s u ch a system, the s i m p l e causal l aws in w hic h s i m i la r cond itions of devia nce produce s i m i la r effects i s not operative. Even more com p l icated models of con t i n ­ gent cause do n o t work, because i t i s necessary t o spec i fy the state o f t h e enti re syste m . I n cybernetic terms, what w e have referred t o as a vi ci o u s c i rcle i s cal l ed positive feedback, and i t i s apparent from the chart that there are a n um ber of feedback loops in the system. The epi sodes of compulsive behavior i nteract with the earl ier crisis, others' responses, and the deviant's self-conception subsystems, and the p layi ng of the deviant role feeds back to the system of soc ia l control and the deviant's self-conception as wel l . U nder proper con­ d itions, deviation i s not damped out by the action of the system, which i s the usual situation in soci a l systems, but is sta b i l i zed or even ampl i fied.

DEV:ANT STER�OTYPE LEARNED A,N D DAILY REAFFIRMED

4,S

DEVIANT REWARDED FOR DEVIAr'a ROLf,PLAYI'lG ANI) PUNISHED FOR

BACK TO COMMUN ITY

F lowchart i nd i cating sta b i l ization of dev i ance i n a s oc i a l system. Heavy I i ne i n dicates deviation­ a m p li fy i ng (positive) feedback; RR: res i d u a l ru le breaki ng.

Figure 5,3.

97

Notes

CONCLUSION

The d i scussion to this poi nt has presented a soc iological theory of the cau­ sation of stab le mental d isorder. S i nce the evi dence advanced in su pport of the theory was scattered and fragmentary, i t can only be suggested as a sti m­ u l us to further d i scussion and research . Among the areas poi nted out for fur­ ther i nvestigation are field studies of the preva lence and d u ration of residual rule-breaking; i nvesti gations of stereotypes of mental d i sorder i n ch i l d ren, the mass medi a, and adult conversations; studies of the reward i ng of stereotyped deviation, of the b lockage of retu r n to conventional rol es, and of the sug­ gest i b i l i ty of rule-breakers in crises. The fi nal causal hypothesi s suggests stud­ i es of the cond itions u nder which normal i zation and label i ng of residual ru le­ b reak i ng occu r. The va riables that may effect the soc i etal reaction concern the nat u re of the ru le-breaki ng, the ru le-breaker h i mself, and the com m u n i ty i n which the ru le-brea k i ng occ u rs. A lthough many of the propositions sug­ gested are la rgely u nverified, they suggest aven ues for i nvesti gating mental d i sorder di fferent from those that are usually fol lowed and the rudi ments of a general theory of deviant behavior. NOTES

1 . For a d i scussion of type casti ng, see Klapp ( 1 962, pp. 5 8 pass i m ) . 2 . For a review of experimenta l evidence, see Mann ( 1 956). For an i nteresti ng demonstration of the i nterrelations between symptoms of patients on the same ward, see Kel l a m and Chassan ( 1 962 ) . 3 . B r i l l a n d Malzberg ( 1 950l. See a lso Hasti ngs ( 1 958). Suic ide is an i mportant exception to these fi ndi ngs. The rate of suicide is reported in a nu m ber of stud ies as considerably h igher among patients and ex patients than among the rest of the pop u lation. Even though the relative rate is h igh, the absol ute rate is sti l l qu ite low. W. 0. Hagstrom suggested this exception to me. 4. For a d iscuss ion, with many i l l u strative cases, of the process i n which per sons play the "dead rol e" and subsequently d ie, see Herbert ( 1 961 ) . 5 . Lemert ( 1 9 5 1 ) provides an extensive d i scussion of th is process under the head i ng, "Lim itation of Participation," pp. 434 440. 6. Th is proposition receives support from Eri kson's ( 1 957) observations. 7. Socio logica l l y, an occupational career can be defined as "the sequence of movements from one position to another in an occupational system made by any i n dividual who works i n that system" (Becker 1 963, p. 24). S i m i larly, a deviant career is the sequence of movements from one stigmatized position to another in the sector of the larger social system that fu nctions to mainta i n soc ial control . For example, the frequently cited progression of young men from probation through detention centers and reform school s to prison, w ith i nterven i ng ti mes spent out of prison, may be con sidered as recurring deviant career. For his d iscussion of deviant careers, see Becker ( 1 963, pp. 2 5 3 9).

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The Soc i a l I nstitution of I ns a n i ty

8 . I n terview o n rad i o station KPFA, Berkel ey, Cal i fo rn i a, as reco l l ected by the a ut hor. 9 . Cf. Lemert ( 1 9 5 1 , pp. 5 1 5 3 , 55 68); Goffman ( 1 9 5 9 , p p . 1 34 1 3 5) ; Me chanic ( 1 963). For a l ist of s i m i l a r factors in the reacti o n to physical i l l ness, see Koos ( 1 954, pp. 30 38). 1 0. For a n expl ic i t treatment of feedback, see Lemert ( 1 9 62 ) . 1 1 . W. Buckley s uggested the use of t h i s flowchart and provided h e l p i n i n ter­ pret i n g the theory in cybernetic terms.

Ill TH E POWER OF T H E PSYCH IATRIST

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6 Decisions i n Medici n e 1

The d i scussion to th i s point has concerned a theory of stable menta l i l l ness. In th i s chapter and the fol lowi ng chapter, our attention sh ifts from theory to practice. Th i s chapter d i scusses a decis ion-ma k ing problem that psych iatry shares with general med i c i ne. Members of profess ions such as law and med­ i c i ne freq uently are confronted with u ncertai nty in the cou rse of the i r routi ne duties. I n these c i rcumstances, i nformal norms have developed for hand l i ng u ncerta i nty so that para lyz i ng hes i tation i s avoided. These norms are based upon assumptions that some types of error are more to be avoi ded than oth­ ers-assumptions so bas ic that they are usua l l y taken for granted, are seldom d iscussed, and are therefore s l ow to change. The pu rpose of th i s chapter i s to describe one important norm for han d l i ng u ncertai nty i n medical d i agnosi s, that j udging a s i ck person wel l i s more to be avoided than j udging a wel l person s i ck, and to suggest some of the con­ sequences of the app l i cation of th i s norm in medical practice. Apparent l y th i s norm, l i ke many i m portant c u l tural norms, "goes w ithout sayi ng" i n t h e sub­ c u lture of the medical profession; in form, however, i t resembles any decision rule for gu i d i ng behavior u nder con d itions of u ncerta i nty. I n the d i scussion that fol l ows, dec ision rules in law, stati sti cs, and med i c i ne are compared in order to i nd i cate the types of error that are thought to be the more i mportant to avo i d and the assumptions u nderlying t h i s preference. On the basi s of

1 01

1 02

Decisions i n Med i ci ne

recent fi n d i ngs of the widespread d i stribution of elements of d i sease and deviance in norma l pop ulations, the assumption of a u n iform re lations h i p between d i sease s i g n s and i mpai rment i s critic i zed . F i n a l l y, it i s suggested that to the extent that physicians are g uided by th i s med i cal decision ru le, they too often p lace patients i n the " sic k role" who cou l d otherw i se have cont i n ued in the i r normal pursu i ts. To the extent that physicians and the publ i c are b iased toward treatment, the "creation" of i l l ness ( i .e., the production of u n necessary i mpai rment) may go hand in hand with the prevention and treatment of d isease in modern med i c i ne. The magnitude of the b i as toward treatment in any s i ngle case may be q u i te sma l l , s i n ce there are probably other med ical dec i s ion rules ("When in doubt, delay you r deci sion") that cou nteract the rule d i sc u ssed here. Even a small bi as, however, if it is relatively constant throughout Western society, can have effects of large magnitude. S i n ce th i s argu ment i s based largely on fragmentary evidence, i t i s i ntended merely to sti m u l ate further d i scussion and research rather than to demonstrate the val id i ty of a po i nt of view. The d i scussion begins with the consideration of a decision rule in law. I n cri m i na l trials i n England and the U n ited States, there i s an exp l i c i t rule for arriv i ng at decisions i n the face of u ncertai nty: A man i s i n nocent until proven g u i l ty. The mea n i ng of th i s rule i s made clear by the Engl i sh common­ l aw defi n ition of the phrase "proven g u i l ty," wh i ch, accord ing to tradition, is that the j udge or j u ry m ust fi nd the evidence of gu i lt compel l i ng beyond a reasonable doubt. The basi c legal rule for arriving at a deci s ion i n the face of u ncertai nty may be briefly stated : When i n doubt, acqu it. That is, the j u ry or j udge m ust not be eq ual ly wary of erroneously convi cting or acqu itting: the error that i s most i m portant to avoid i s to erroneously convi ct. Th i s concept is expressed in the maxi m, " Better a thousand gu i lty men go free, than one i n nocent man be convicted." The reason s u nderlying t h i s rule seem c lear. It i s assu med that in most cases a conviction w i l l do i rreversi b l e harm to an i nd ividual by damaging h i s reputation i n t h e eyes o f h i s fel l ows. The i nd ividual i s seen a s weak a n d de­ fenseless relative to soc iety, and therefore i n no pos i tion to susta i n the con­ sequences of an erroneous dec i s i o n . An erroneous acq u i tta l, on the other hand, damages soc iety. If an i nd ividual who has actu a l l y com m i tted a crime i s not p u n ished, he may com m i t the crime aga i n, or more i mportant, the de­ terrent effect of p u n is h ment for the violation of th i s c r i me may be d i m i n i shed for others. A l though these are serious outcomes, they are genera l ly thought not to be so serious as the consequen ces of erroneous conv i ct i o n for the i n nocent i nd ividual, s i n ce soc iety i s able to susta i n an i ndefi n i te n um ber of such errors without serious consequences. For these and perhaps other rea­ sons, the dec ision rule to assume i n nocence exerts a powerfu l i nfluence on legal proceed i ngs.

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Type 7 and Type 2 Errors

TYPE 1 A N D TYPE 2 ERRORS

Dec i d i ng on gu i lt or i n nocence is a specia l case of a problem to which statisticians have given cons i derable attentio n : the testing of hypotheses. S i nce most scientific work is done with samples, statisticians have developed tech n iques to guard aga i n st resu lts that are due to chance sampl i ng fluctua­ tions. The problem, however, i s that one may reject a finding that was actu­ a l l y correct as due to sampl i ng fluctuations. There are, therefore, two ki nds of errors: rejecting a hypothes i s that i s true and accepti ng one that i s fa lse. U s u a l l y the hypothesi s is stated so that the former error (rejecti ng a hypoth­ esis that is true) is the error that is thought to be the more i mportant to avoid. Th i s type of error i s ca l l ed an "error of the fi rst k i nd," or a Type I error. The latter error (accept i ng a hypothes i s that is fal se) is the less i mportant error to avoid and is cal led an "error of the second k i nd," or a Type 2 error ( N eyman 1 950, pp. 2 65-2 66). To guard agai nst chance fl uctuations i n sampli ng, statisticians test the prob­ abi l ity that findi ngs cou l d have arisen by chance. At some predeterm i ned probabi l ity (cal led the "alpha level"), usua l ly 0.05 or less, the poss i b i l ity that the fi ndi ngs arose by chance i s rejected . Th i s leve l means that there are 5 chances i n 1 00 that one wi II reject a hypothesi s that i s true. Although these 5 chances i nd i cate a rea l risk of error, it is not common to set the level much lower (say 0.001 ) because t h i s rai ses the probabi l ity of making an error of the second kind. A s i m i lar d i lemma faces the j udge or j u ry in dec i d i ng whether to convict or acq u i t i n the face of uncertai nty. Particu larly i n the adversary system of law, where profess ional attorneys seek to advance their argu ments and refute those of the i r opponents, there is often considerable u ncertai nty even as to the facts of the case, l et alone i ntangibles l i ke i ntent. The maxim, "Better a thousand gu i l ty men go free, than one i nnocent man be convicted," wou ld mean, if taken l i tera l l y rather than as a rhetorical flourish, that the alpha level for legal dec i s ions i s set qu ite low. Although the legal dec ision rule is not expressed i n so prec i se a form as a statistical decision rule, it represents a very s i m i lar procedu re for dea l i ng with u ncerta i nty. There i s one respect, however, i n which it is qu i te di fferent. Sta­ tistical decision procedu res are recogn i zed by those who use them as mere conve n iences, which can be varied accordi n g to the c i rcumstances. The legal decis ion rule, in contrast, is an i nflexible and b i nd i ng moral rule, which car­ r ies with it the force of long sanction and tradition. The assumption of i nno­ cence is a part of the social i nstitution of l aw in Western society; i t is expl ic­ itly stated in legal codes and i s accepted as legiti mate by j u ri sts and usua l l y b y t h e general popul ace with only occasional grumb l i ng (e.g., a cri m i nal i s seen a s "gett i ng off" becau se o f "legal tec h n i cal ities").

Dec i s i o n s i n Med i c i n e

1 04

DECISION RULES I N MEDICINE

Although the analogou s rule for decisions in med i c i ne is not so expl icitly stated as the rule i n law and probably is considerably l ess rigid, it wou l d seem that there is such a rule in med i c i ne, which is as i mperative i n i ts operation as its a n a log in law. Which error do phys i c ians and the general p u b l i c con­ sider it most i mportan t to avoid: rejecting the hypothesi s of i l l ness when i t is true, or accepting i t when i t i s fa lse? It seems fai rly clear that the rule in med­ i c i ne m ay be stated as: "When i n doubt, con t i n u e to s uspect i l ln ess." That is, for a physi c i a n to d is m i ss a patient when he is actu a l l y i l l is a Type 1 error, and to reta in a patient when he i s not i l l i s a Type 2 error. Most physicians learn early i n their tra i n ing that it is far more c u l pable to d i s m i s s a s i ck patient than to retai n a well one. Th i s ru l e is so pervasive and fu ndamental that it goes u nstated in textbooks on d i agnosis. It i s occasion­ a l ly mentioned expl icitly i n other contexts, however. Neyman ( 1 9 5 0), for example, i n his d i scussio n of X-ray screen i ng for tuberc u losis states: [ I f the patient is actu a l l y we l l, but the hypothesi s that he is sick is accepted, a Type 2 error,] then the patient w i l l suffer some u n justified a n x i ety and, perhaps, w i l l be put to some u n n ecessary expense u n t i l further st ud ies of h i s h ea lth w i l l establ i s h that a n y alarm about t h e state o f h i s chest i s u n fo u n ded . A l so, t h e u n ­ justified precautions ordered b y t h e c l i n ic may somewhat affect i t s reputation. On the other hand, shou l d t h e hypothesi s [of s i ckness] be true and yet the ac­ cepted hypothesis be [that he is wel l , a Type I error] , t h e n the patient w i l l be i n danger o f losing the precious opportu n ity of trea t i n g the i nc i p i ent d isease i n i ts beg i n n i ng stages when the c u re is not so d i ffic u l t. F u rt h e rmore, the oversi ght by the c l i n ic's speci a l i st of the dangerous cond ition wou ld affect the c l i n i c's reputation even more than the u n n ecessary a larm. From t h i s poi n t of v iew, i t appears that t h e error of reject i n g t h e hypothesis [of s ickness] when i t is true is far more important t o avoi d t h a n t h e error of accepti n g the hypothesi s [oi i l l ness] when i t i s fa lse. ( p . 2 70; i ta l ics added)

Although this particular d i scussion pertai ns to tubercu losis, it is perti nent to many other di seases a l so. From cas u a l conversations with physi c ians, the im pression one gai ns is that this moral lesson i s deep l y i ngrai ned in the physi­ c i an's persona l code. It is not on ly physi c i a n s who feel this way, however. Th i s rule is grounded both i n legal proceed i ngs and i n popu l a r sentiment. Although there is some senti ment aga i nst Type 2 e rrors ( u n n ecessary s urgery, for i n stance), i t has nothing l i ke the force and u rgency of the sentiment aga i nst Type I errors. A physician who d i s m i sses a patient who subsequently d i es of a d i sease that shou l d have been detected is subject not only to legal action for neg l i ge nce and possible loss of l i cense for i ncompetence, but a l so to moral condemna­ tion from his col leagues and from his own conscience for his del i nquency.

Decision Rules in Medicine

1 05

N oth i ng remote l y resembl i ng t h i s amount of moral and legal suasion i s b rought to bear for committ i ng a Type 2 error. I ndeed, th i s error i s someti mes seen as sou n d c l i n ical practice, i n d icating a health i l y conservative approach to med i c i ne . T h e d i scussion to th i s poi n t suggests that physicians fol low a decision rule that may be stated, "When in doubt, d i agnose i l lness." If physicians are ac­ tua l l y i nfluenced by t h i s r u l e, then studies of the val i d i ty of d iagnosi s shou l d demonstrate the operation of t h e rule. That i s, w e should expect that objec­ tive stu d ies of d iagnosti c errors shou l d show that Type I and Type 2 errors do not occ u r with equal frequency, but i n fact, that Type 2 errors far outn u m ber Type I errors. U nfortunately for o u r pu rposes, however, there are apparently only a few studi es that provide the type of data that wou l d adequately test the hypothes i s . A l though stu d i es of the rel iabi l ity of d i agnosis aboun d (Garland 1 95 9 ) showi ng that physicians d i sagree with each other in thei r d iagnoses of the same patients, these stud ies do not report the va l id ity of d i agnosi s o r the types of error that a re made, with the fol lowi n g exceptions. vVe can i nfer that Type 2 errors outnu mber Type 1 errors from Bakw i n 's ( 1 9 4 5 ) study of physicians' j u dgments regardi n g the adv isab i l i ty of tonsi l lec­ tomy for 1 000 school c hi l d ren: O f these, some 6 1 1 h a d had t h e i r tons i l s removed. The rema i n i ng 3 89 were then exa m i ned by other physicians, and 1 74 were selected for tonsi l l ectomy. Th is left 2 1 5 c h i l d ren whose ton s i l s were apparently normal. Another group of doctors was put to work exa m i n i n g these 2 1 5 chi ldren, and 99 of them were adjudged in need of tonsi l lectomy. Sti l l another group of doctors was then em­ p l oyed to exa m i ne the rema i n i ng c h i l d ren, and nearly one ha lf were recom mended for operation. (pp. 69 1 697)

A l most half of group of chi ld ren were j udged to be i n need of the oper­ atio n . Even ass u m i ng that a sma l l proportion of c h i l d ren needi n g ton s i l l ec­ tomy were m issed in each exa mi nation (Type I error), the n umber of Type 2 errors i n t h i s study far exceeded the n um ber of Type 1 errors. In the fie l d of roentgenology, studies of d iagnostic error are apparently more h ighl y developed than in other areas of med i c i ne. Garland ( 1 959, p . 3 1 ) summarizes these fi ndi ngs, report i n g that i n a study of 1 4, 86 7 fi lms for tu­ bercu losis signs, there were 1 2 1 6 positive rea d i ngs that turned out to be cl in­ i ca l l y negative (Type 2 error) a nd o n l y 24 negative readi ngs that tu rned out to be c l i n ical l y active ( Type 1 error)! Thi s rati o (about 5 0: 1 ) i s apparently a fa ir ly typical fi n d i ng i n roentgenograph i c studies. S i nce physicians are wel l aware o f the prov i s ional natu re of rad iological fi ndi ngs, this great d i screp­ ancy between the frequency of the types of error in fi l m scree n i ng is not too a larmi ng. On the other hand, it does provide objective evidence of the op­ eration of the decis ion rul e, " B etter safe than sorry."

Deci sions in Medicine

1 06

BASIC ASSUMPTIONS

The logic of th i s dec i s io n rule rests on two assu mptions: F irst, disease i s u s u a l l y a determi nate, i nevi tably u nfold i ng process, whi ch, i f u ndetected a n d u ntreated, w i l l grow t o a poi nt where i t endangers t h e l ife or l i m b of t h e i n­ d ividual and, i n the case of contagious di seases, the l ives of others. Th is is not to say, of course, that phys icians th i n k of a l l d i seases as determ i n ate: Wit­ ness the concept of the 0ben ign" condition. The poi n t here is that the i magery of disease that the physician u ses i n attempting to reach a deci sion, h i s work­ i ng hypothes i s, is usually based on the determ in istic model of d i sease. Sec­ ond, medical d i agnosi s of i l lness, u n l i ke legal j ud gment, is not an i rreversible act that does u ntold damage to the status and reputation of the patient. A phys ician may search for i l l ness for an i ndefi nitely long ti me, causi ng i ncon­ ven ience for the patient, perhaps, but in the typical case, do ing the patient no i rrad i cable harm. Obviously, aga i n , physicians do not always make this assumption. A physician who suspects epilepsy i n a truck driver knows ful l wel l that h i s patient w i l l probab l y never drive a truck aga i n i f the d i agnosi s i s m ade, a n d the phys i c i a n w i l l go to great lengths t o avoid a Type 2 error i n t h i s s i tuation. S i m i l a rly, if a physician suspects that a partic u l a r patient has hypochondriacal trends, the physi c i a n w i l l lea n in the d i rection of a Type 1 error i n a situation of u ncertai nty. These and other s i m i l ar situations a re ex­ ceptions, however. The physician's usual working assumption is that med i ca l observation a n d d i agnosis, i n itself, is neutral a n d i n nocuous relative to the dangers resu lting from d i sease.2 In the l i ght of these two assum ptions, therefore, it is seen as far better for the phys ician to chance a Type 2 error than a Type I error. These two as­ sumptions w i l l be exami ned and criticized in the remainder of the chapter. The assumption that Type 2 errors a re relatively harm less w i l l be considered first. In recent d iscussions, it is i ncreas ingly recogn i zed that i n one area of med­ i c ine, psych iatry the assumption that medical d i agnos i s can c ause no i rre­ versible harm to the patient's status i s dubious. Psychiatric treatment, in many segments of the pop u l ation and for many occupations, rai ses a question a bout the person's soc i al status. It cou ld be a rgued that i n making a medi cal d i agnos i s the psych i atrist comes very c lose to making a legal decision, with its ensuing consequences for the person 's reputation. One may argue that the Type 2 error in psych iatry, of j udging a wel l person s ick, is at l east as rn uch to be avoi ded a s the Type I error, of judging the sick person wel l . Yet the psych iatrist's mora l orientation, s i nce he is fi rst and foremost a physician, is guided by the medi cal, rather than the lega l, decision ru le. The psychiatrist cont inues to be more w i l l ing to err on the conservative s i de, to d i agnose as i l l when the person is healthy, even though i t is no longer clear that this error is any more des i rable than its opposite.

Basic Assumptions

1 07

There i s a more fu ndamental question about th i s dec i s ion ru le, however, which concerns both physical i l l ness and mental d isorder. Th i s question pri­ marily concerns the fi rst assumption: that d isease is a determ i nate process. It a l so i m p l icates the second assumption: that med ical treatment does n o t have i rrevers i b l e effects. In recent years, physic ians and soc ia l scientists have reported finding d is­ ease s igns and deviant behavior preva lent in normal, n on i nstitutiona l i zed popu lations. It has been shown, for i nstance, that deviant acts, some of a se­ rious nature, are widely a d m i tted by persons i n ran dom samples of normal popu lations (Wal lerste i n and Wy le 1 947; Porterfield 1 946; K i nsey, Pomeroy, and Marti n 1 94 8 ) . There i s some evidence that suggests that grossly devia nt, "psychotic" behavior has at least temporarily existed i n relatively large pro­ portions of a normal popu lation ( P l u n kett and Gordon 1 9 60; C l ausen and Yarrow 1 9 5 5 ) . Fi nal l y, there is a grow i ng body of ev idence that many signs of physical d i sease are d istributed q u i te widely i n normal popu lations. A s u r­ vey of simple h igh bl ood pressure i nd i cated that the preva lence ranged from 1 1 .4 to 3 7 . 2 % i n the various s ubgroups stud ied ( Rautaharj u, Karvonen, and Keys 1 96 1 ) . 3 As stated in Chapter 4, physical defects and "psych i atric" deviancy exi st in an u ncrysta l l i zed form in large segments of the popu lation. Lemert ( 1 9 5 1 ) ca l l s t h i s type of behavior, which i s often transitory, primary deviation. I n h i s d i scussion o f t h e doctor-patient re lationsh i p, B a l i n t ( 1 9 5 7) speaks o f s i m i ­ lar behavior a s t h e " u norga nized phase of i l l ness" Bal i nt seems t o take for granted, however, that patients wi l l eventual ly "settle down" to an "organ­ ized" i l l ness. Yet it i s possi ble that other outcomes may occur. A person i n this stage may change jobs or wives i nstead, or merely conti n u e in the primary deviation state i ndefi n i tely, without getting better or worse. Th i s d i scussion suggests that i n order to esti mate the probab i l i ty that a per­ son with a d i sease si gn wou ld become i ncapacitated because of the devel­ opment of disease, investigations qu ite u n l i ke existi ng studi es wou l d need to be conducted . These wou l d be longitud i na l stud ies i n a random sample of a normal popu lation, of outcomes i n persons having s igns of d iseases i n which no attempt was made to arrest the d i sease. It i s true that there are a n u m ber of longitud i nal studies in which the effects of treatment are compared with the effects of nontreatment. These studies, however, have always been con­ d ucted with c l i n ical groups rather than with persons with d isease signs who were located in field stud ies.4 Even cl i n ical trials appear to offer many d iffi­ cu l ties, both from the eth ical and scientific poi nts of view ( H i l l 1 960). These d iffi c u l ties wou l d be i ncreased many ti mes i n control led field trials, as wou l d t h e prob lems that concern t h e amount o f t i m e a n d money necessary. With­ out such studies, nevertheless, the mean i ng of many common di sease signs rem a i n s somewhat equ ivocal . G iven the relative l y s ma l l amount of know ledge about the d i stributions

1 08

Decisions i n Med i c i ne

a n d natural outcomes of many d iseases, i t i s pos s i b l e that o u r conceptions of the danger of di sease are exaggerated. To mention aga i n the dramatic ex­ ample cited earl ier, u nti l the late 1 940s, h i stoplasmos i s was thought to be a rare tropical d i sease with a u n iform fata l outcome. Recently, however, it was d iscovered that it is widely prevalent and with fatal outcome or i mpairment extremely rare (Schwartz and Baum 1 95 7). I t i s conceivable that other d is­ eases, such as some types of heart d i sease and mental d isorder, may prove to be s i m i l ar in character. Al though no actuarial studi es h ave been made that wou l d yield the true probab i l ities of i mpai rment, physicians usua l l y set the Type 1 level q u i te h igh because they bel ieve that the probabi l ity of i m­ pairment from making a Type 2 error i s qu ite l ow. Let u s now examine that assumption.

T H E " S I C K ROLE"

If, as has been argued here, m uch i l l ness goes u n attended without serious consequences, the assumption that med ical d iagnos i s has no i rreversible ef­ fects on the patients seems questionable. The patient's attitude to h i s i l l ness is usua l l y considerably changed d u ring, and by, the series of physical exa m i nations. These cha nges, which may profoundly i nfluence the cou rse of a chronic i l l ness, are not taken seriously by the med ical profession and, though occas iona l l y mentioned, they have never been the subject of a proper scientific i nvestigation. (Ba l i nt 1 95 7, p. 43 )

There are grounds for bel i evi ng that persons who ava i l themselves of pro­ fessional services are u nder considerab le stra i n and tension (i f the prob lem cou l d have been eas i l y solved, they wou ld probably have used more i nformal means of handl i ng it). Social-psychological pri nciples i ndi cate that person s u nder stra i n are h ighly suggesti ble, particu larly to suggestions from a presti­ gious sou rce, such as a physic ia n . It can be argued that t he Type 2 error i nvolves t h e danger o f having a per­ son enter the "sick role" (Parsons 1 950) in c i rcumstances where no serious res u l t wou l d ensue if the i l l ness were un attended. Perhaps the combi nation of a physician determi ned to find d isease signs, i f they are to be fou nd, and the suggestible patient, searc h i ng for subj ective symptoms among the many amorphous and u sua l l y u n atten ded bod i ly i mpu l ses, i s often sufficient to u nearth a d i sease that changes the patient's status from that of we l l to sick and may a l so have effect on his fam i l i a l and occupational status. [In Lemert's ( 1 95 1 ) terms, the i l l ness wou l d be secondary devia tion after the person has entered the sick role.] There i s a considerable body of evidence in the med ical l i terat u re con-

The "Sick Role "

1 09

cern i ng the process i n which the physi c i a n u n n ecessarily causes the patient to enter the sick role. Thus, in a d i scussion of ''iatrogenic" (physician-induced) heart disease, this poi nt is made: The physi c i a n , by ca l li n g attent i o n to a m u r m u r o r some card iovasc u la r ab­ n o rm a l i ty, even though fu n ct i o n a l l y i nsign i fi ca nt, may preci p i tate [symptoms of heart d i sease] . The expe r i ence of the work c l assification u n its of cardiac in i n dustry programs, where patients w i th cardiovasc u l a r d i sease a re eval u ated as to work gives i m p ressive evi dence regard i n g the h igh i n c i dence of such fu nctional ma n i festations in persons with the d iagnos i s of cardi ac lesion. (Warren and Wolter 1 954, pp. 77--84)

Although there i s a ten dency in med ic i n e to d is m i s s t h i s p rocess as d u e t o q u irks o f particular patients (e.g., as m a l ingeri ng, hypochondriasis, or as "merely functional d isease," that i s, functional for the patient), causation prob­ ably l ies not i n the patient but in med ical procedu res. Most people, perhaps, if they actually have the d i sease signs and a re told by an authority, the physi ­ c i a n , that they a re i l l , w i l l obligingl y come u p with appropriate symptoms . A case h i story w i l l i l lustrate t h i s process. Under the headi n g, "It may be wel l to l et sleeping dogs l ie," a phys i c i a n recounts the fol lowi n g case: Here is a woman, aged 40 years, who is admitted w i th symptoms of congestive card iac fai l u re, va l v u l a r d isease, m itral stenosi s a n d a u r i c u l a r fibri l l at i o n . She tel l s us that she did not know that there was anyth i n g wrong with her heart and that she had had no symptoms u p to 5 years ago when her chest was x-rayed in the course of a mass rad iography exam i nation for tuberc u l o s i s . She was not suspected and th is was o n l y done in the course oi routi ne at the factory. Her l u ngs were pronounced c lear but she was told that she had an e n l a rged heart and was advised to go to a hospita l for i nvestigati o n and treatment. From that time she began to suffer from sym ptoms breat h l essness on exertion and has been i n the hospital 4 or 5 t i mes si nce. Now she i s here with congestive heart fai lure. She can not u ndersta nd why, from the t i m e that her e n l a rged heart was d iscovered, she began to get symptoms. ( G a rd i ner H i l l 1 95 8, p. 1 5 8 )

What m akes this kind of "role-taking" extremely i mportant i s that it can occu r even when the d i agnostic label is kept from the patient. By the way he is hand led, the patient can usually i nfer the n ature of the diagnosi s, si nce i n h i s u ncertai nty a n d anxiety he i s extremely sensitive to subtleties i n the physi­ cian's behavior. An example of thi s process (already cited in Chapter 4) is found in reports on treatment of battle fatigue. Speaking of psych iatric patients i n the S i c i l ian campaign d u r i n g World War I I, a psych i atrist notes: A l though patients were received at t h i s hospital with i n 24 to 4 8 h o u rs after the i r breakdown, a d i sappo i nting n u m ber, approxi mately 1 5 pe r cent, were salvaged for combat d uty. . . [A] ny therapy, i nc l u d i ng usual i n terview methods that

1 10

Dec i sions in Med i ci ne

sought to u n cover basic emotional conflicts or attempted to relate cu rrent be havior and symptoms w ith past personal ity patterns seem i ngly provided pa tients w ith logi cal reasons for the i r combat fa i l ure. The i n sights obtai ned by even such m i l d depth therapy read ily convi nced the patient and often his ther­ apist that the l i m it of combat endurance had been reached as proved by vul nerable personal ity traits. Patients were obligingly cooperative i n supply i ng deta i ls of their neurotic c h i l dhood, previous emotional difficulties, lack of ag gressiveness and other dependence tra its. ( G l ass 1 95 3 )

G l as s goes on to say that removal o f the soldier from h i s u n i t for treatment of any kind usually res u l ted in l ong-term neuros is. In contrast, i f the so l d ier were given only superficial psych iatric attention and kept with his unit, chron ic i mpairment was usually avoi ded . The i m p l i cation i s that removal from the m i l itary unit and psych iatric treatment symbol izes to the sold ier, behaviora l l y rather t h a n w i t h verbal labels, t h e ''fact" that he i s a mental case. The traditional way of i nterpret i n g these reactions of the soldiers, and perhaps the civi l i an cases, i s i n terms of m a l i ngeri ng or feign i ng i l l ness. The process of tak i ng roles, however, as it is conceived of here, is not completely or even l argely vo l u ntary. [For a sop histicated d i scussion of role-pl ayi ng, see Coffman ( 1 959, pp. 1 7-2 1 ). ] Vaguely defi ned i mpu l ses become " rea l " to the parti ci pants when they a re orga n i zed u nder any one of a n u m ber of more or less i nterchangeable soc ial roles. I t can be argued that when a person i s in a confused and suggesti b l e state, when he orga n i zes h i s fee l i ngs and behavior by using the sick role and when his choice of roles is val idated by a physician or others, he i s "hooked" and w i l l proceed on a career of chron ic i l l ness." IMPLICATIONS FOR RESEARCH

The hypothesi s suggested by the precedi ng d i scussion is that physicians and the public typ ica l l y overva lue medical treatment relative to nontreatment as a course of action in the face of u ncertai nty, and t h i s overva l uation resu lts in the creation as we l l as the prevention of i mpairment. This hypothesis, s i n ce it is based on scattered observations, i s presented only to poi nt out several areas where systematic research is needed. From the poin t of v i ew of assessi ng the effectiveness of medical practice, th i s hypothes i s is probably too general to be used d i rectly. Needed for such a task are hypotheses concern ing the con d itions u nder which error i s l i kely to occ u r, the type of error that i s l i kely, and the consequences of each type of error. Sign i ficant d i mensions of the amount and type of error and its con­ sequences wou l d appear to be characteristics of the disease, the physician, the patient, and the orga n i zational setting in which d iagnos i s takes place. Thus, for diseases such as pneumon ia, which produce al most certa i n i mpai rment u n less attended and for which a quick and h i gh l y effective cure i s ava i l ab le,

Implications for Research

111

the hypothesi s i s probably largely i rrelevant. On the other hand, the hypoth­ esis may be of considerable i mportance for d iseases that have a less certai n outcome and for which exi sti ng treatments a re protracted a n d of u ncerta i n va lue. Mental d i sorders and some types of heart d i sease a re cases in point. The wor k i ng phi losophy of the physic ia n is probably relevant to the pre­ domi nant type of errors made. Physi c ians who genera l l y favor active i nter­ vention probab l y make more Type 2 errors than physi c i a ns who view the i r t reatments only as assistance for nat u ra l bod i l y reactions to The physicia n's perception of the persona l i ty of the patient may also be relevant; Type 2 errors are less l i kely if the phys ician defines the patient as a "crock," a person overly sensitive to d iscomfort, rather than as a person who ignores or den ies d i sease. Finally, the orga n i zational setting is relevant to the extent that it i nfluences the relationship between the doctor and the patient. In some contexts, as i n medical practice i n organizations such a s the m i l i tary o r i ndustrial setting, the physician is not so l i kely to feel personal responsi b i l i ty for the patient as h e wou ld i n other contexts, s u c h a s private practi ce. Thi s m a y b e due i n part to the cond itions of financial remuneration and, perhaps equ a l l y i m portant, the sheer vo lu me of pati ents dependent on the doctor's time. Cultural or class d i fferences may a lso affect the amount of social d i stance between doctor and patient a n d therefore the amount of respons i b i l ity that the doctor feels for the patient. Whatever the sources, the more the physician feels persona l l y re­ sponsible for the patient, the more l i ke l y he is to make a Type 2 error. To the extent that future research can i nd icate the cond itions that infl u ­ ence t h e amou nt, type, a n d consequences o f error, such research c a n make di rect contri butions to medical practice. Three types of research seem nec­ essary in order to establ ish the true ri sks of i mpai rment associ ated with common d isease signs. F irst, control led field trials of treated and u ntreated outcomes i n a normal population woul d be needed . Second, perhaps i n conj u n ction with field tria ls, exper imental studies of the effect of sug­ gestion of i l l ness by physi c i a n s and others wou ld be necessary to determi ne the risks of unnecessary entry i nto the sick role. F i n a l l y, studies of a mathematical nature seem to be called for. Suppose that physicians were p rovided with the results of the studies suggested here. H ow cou ld these findings be i n troduced i nto medical practice as a corrective to cu ltural and professional biases in dec i sion-making procedures? One prom­ ising approach is the strategy of eva l uating the relative uti l i ty of a lternative courses of action based upon decision theory or game theory (Chernoff and Moses 1 959). Led ley and Lusted (1 959) reviewed a nu mber of mathematical tec h ni ques that may be appl icable to med ical decision-maki ng, one of these techn iques being the use of the "expected val ue" equation, wh ich is derived from game theory. Although the i r d iscussion perta i ns to the relative value of two treatment

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Decisions i n Medicine

procedu res, i t i s also relevant, with only s l i ght changes in word i ng, to deter­ m i n ing the expected val ues of treatment relative to nontreatment. The ex­ pected val ues of two treatments, they say, may be calcu lated from a s i mple expression i nvo l v i ng only two k i nds of terms: The probabi l i ty that the d i ag­ nosis is correct and the abso l u te va l ue of the treatment (at i ts s i mplest, the absol ute val ue i s the rate of c u re for persons known to have the d i sease) . The "expected val u e" of a treatment i s : 5 E 1 = p5 V5 + ( 1 - p5 )v(; that is, the expected val ue E1 of a treatment is the probabi l ity p that the pa­ tient has the d i sease, m ult ipl i ed by the val ue (or "cost") v of the treatment for patients who actua l l y have the d isease, p lus the probabi l ity that the patient does not have the d i sease ( 1 - p), mu ltipl ied by the va l u e of the treatment for patients who do not have the d isease, where the su perscript refers to the way the patient is treated (s, sick; h, healthy) and the subscript refers to h is actua l con d i tion (s, s i ck; h, healthy). S i m i larly, the expected va l ue of nontreatment is

En = p,s Vsh + (1 + Ps )�hh that is, the expected valu e En of nontreatment i s the probabi l i ty that the pa­ tient has the d i sease multipl ied by the va l ue (or "cost") of treating a person as healthy who is actually s ick, p lus the probabi l ity that the patient does not have the d i sease, m u lt ip l ied by the va lu e of not treating a healthy person. The best course of action i s i nd icated by compari ng the magn i tude of E1 and En. If E1 i s larger, treatment i s i n d i cated. If En i s l arger, nontreatment i s i n­ d icated. Eva l uati ng these equations i nvolves est i mati n g the probab i l ity of correct d iagnos i s and constructing a payoff matrix for the va l ues of v� (pro­ portion of patients who actua l l y had the d i sease who were c u red by the treatment), v� (the cost of treating a healthy person as s i ck: i n conven ience, worki ng days l ost, surgical r isks, u n n ecessary entry i nto sick role), v�' (cost of treating a sick person as wel l : a question i nvo lving the proportions of persons who spontaneously recover and the seriousness of resu l ts when the d i sease goes unchecked), and final ly, v h (the val ue of not treating a healthy perso n : h med i cal expenses saved, work i n g days, etc.). To i l l u strate the use of the eq uation, Led ley and Lusted assign arbitrary ab­ sol ute val ues in a case because, as they say, "The decision of va l ue problems frequently involves i ntangibles such as moral and eth ical standards which m ust, i n the last analysis, be left to the physician's j udgment" ( 1 959, p. 1 6) . O n e may argue, however, that it i s better t o develop a techn ique for system­ atica l l y determi n i ng the absolute val ues of treatment and nontreatment, crude though the techn ique may be, than to leave the problem to the perhaps re­ fi ned, but nevertheless obscu re j udgment processes of the physi ci an . Partic­ u larly in a matter of comparing the val ue of treatment and nontreatment, the

Implications for Research

113

problem is to avoid b i ases i n the phys i c i a n 's j udgment due to the kind of moral orientation d i scussed previously. I t i s possi b l e, moreover, that the difficu lty met by Ledl ey and L usted i s not that the factors to be eva l u ated a re " i ntangibles," but that they a re expressed i n see m ingly i ncom mensurate u n its. How does one weigh the risk of death aga inst the monetary cost of treatment? How does one weigh the risk of phys­ i c a l or soc i a l disabi l ity aga inst the risk of death ? Although these are difficult questions to a nswer, the idea of leaving them to the physi c i a n's ju dgment is probably not conducive to a n u nderstanding of the problem. Fol lowi ng the lead of the econo m i sts in the i r studies of uti l ity. it may be feasi ble to reduce the various factors to be weighed to a common u n it. How cou ld the benefits, costs, a n d risks of a l ternative acts i n med i c a l practice be expressed i n monetary u n its? One sol ution may be to use payment rates i n d i sabi l ity and l ife i nsurance, whi ch offer a comparative eva luation of the "cost" of death and permanent a n d temporary disab i l i ty of various degrees. Although this approach does not i n c l ude everythi ng that physicians weigh i n reach i ng decisions (pa i n and sufferi ng can not be weighed i n this frameworkL i t does i nc l ude many of the major factors. I t therefore wou l d prov ide the opportun i ty of constructi ng a fai rly real istic payoff matrix of absol ute va lues, which wou l d then a l low for the determi nation of the relative val u e of treat­ ment and nontreatment using the expected value equation. G athering data for the payoff matrix may make i t possible to explore a n otherwise a l most i naccessi b l e prob lem: the sometimes subtle confl icts of i n ­ terest between t h e phys i c i a n a n d the patient. Although i t i s fai rl y c l e a r that medical i ntervention is u n n ecessary in part i c u l a r cases, and that i t is proba­ b l y done for fi nancial gai n (Trussel, Ehrl ich, and Morehead 1 9 62), the eval­ uation of the i nfluence of remuneration on diagnosi s and treatment is prob­ a b l y i n most cases a fai rly i ntricate m atter, req u i ri ng preci se techn iques of i nvesti gation. If the payoff were calculated i n terms of va l ues to the patient and val ues to the physician, such p roblems cou l d be explored. Less tangi ble val ues such as conven ience and work satisfactions could be i ntrodu ced i nto the matrix. The fol lowi n g statements by psyc h iatrists were taken from Holl i ngshead and Red l ich's ( 1 9 5 8) study of soc i al class and mental d i sorder: "See i ng h i m every mor n i n g was a chore; I had to put h i m on my back and carry him for a n hour." " H e had to get attention i n l arge closes, and th i s was hard to do." "The patient was not i n teresti ng or attractive; I had to repeat, re­ peat, repeat." "She was a poor unhappy, m i serable wom an-we were worlds apart" (p. 344). Th i s study strongly suggests that psych i atric d iagnos i s and treatment are i nfluenced by the payoff for the psych i atrist as well as for the patient. I n any type of medical dec ision, the use of the expected val u e equation may show the exten t of the confli ct of i nterest between the physi c i a n and patient and thereby shed l i ght on the complex process of medical dec is i on-maki ng.

1 14

Decisions i n Med i c i ne NOTES

1 . An earl ier version of th is chapter was presented as a paper at the Conference on Mathemati cal Models in the Behavioral Sciences, sponsored by the Western Management Science Institute, U n iversity of Ca l i forn i a at Los Angeles, Cambria, Ca l ifornia, 1 96 1 . 2 . Even though this assumption is widely held, it is vigorously criticized within the medical profession. See, for example, Darley ( 1 959). For a witty criticism of both assumptions, see Ratner ( 1 962). 3. Cf. Stokes and Dawber ( 1 959) 4. The Fram ingham Study i s an exception to this statement. Even in this study, however, experimenta l procedures (random assignment to treatment and nontreat ment groups) were not used (Dawber, Moore, and Mann 1 95 7 ) . 5 . Some o f the fi ndi ngs o f t h e Purdue Farm Card i ac Project support t h e position taken i n the chapter. It was found, for example, that " iatrogen i cs" took more health preca utions than " h i dden card iacs," suggesting that entry into the sick role can cause more soc i a l i ncapacity than the actual d i sease does. See Ei chorn and Anderson ( 1 962 ).

7 N egoti ati n g Reality Notes on Power in the Assessment of Responsibility1

T h is chapter shows the appl ication of l abel i n g i deas to two particular contexts: sessions with cl ients by a defense lawyer and by a practicing psychiatrist. La­ bel i ng concepts are very abstract. In order to u nderstand their i m pl ications, it is necessary to observe the i r effects in concrete, particular events. The label­ i ng that the psychiatri st is doi ng in the i nterview below is very subtl e; it is not completel y articulated in words and is probably outside the awareness of both the patient and the psych iatrist. Yet i ts effects are very constra i n i ng. The nor­ mal i zation being practiced by the defense l awyer is also mostly nonverbal . I n h i s case, however, he i s probably aware of what he i s doi ng. Th i s chapter pro­ vides a very deta i l ed and expl i ci t contrast between the processes of labe l i ng and normal ization. The u se of i n terrogation to reconstruct parts of an i nd ividual's past h i story is a common occu rrence i n h u man affa i rs. Reporters, j eal o u s lovers, an d pol i cemen on the beat are often faced w it h t h e task of determ i n ing events i n another person's I ife and t he extent t o which he was responsible for those events. The most dramatic use of i nterrogation to determ i ne respo n s i b i l ity i s i n cri m i nal trials. A s i n everyday l ife, cri m i nal trials are concerned w i t h both

1 15

1 16

Negotiating Rea l ity

act and i ntent. Courts, i n most cases, first determ i ne whether the defendant performed a lega l l y forbidden act. If i t i s found that he did so, the court then m ust decide whether he was " respo n sib le" for the act. Recon structive work of th i s type goes on less d ramatica l ly in a wide variety of other sett i ngs, as wel l . The soc i a l worker determi n i n g a c l i ent's e l i g i b i l i ty for u nempl oyment compensation, for example, seeks not only to establ is h that the c l ient actu­ a l ly is u nemployed, b ut that he has actively sought employment ( i .e., that he h i mself i s not respo n sib le for bein g out of work). Thi s ch apter contrasts two perspectives on the process of reconstructing past events for the p urpose of fixi ng respon sib i I ity. The first perspective stems from the common sense notion that i nterrogation, when it is sufficiently ski l l­ ful , is essenti al l y neutra l . Responsibi l ity for past actions can be fixed absol utely and i ndependentl y of the method of reconstruction. Th i s perspective is held by the typical member of society, engaged in his day-to-day tasks. I t i s a lso held, in varyi ng by most professional i nterrogators. The basic work­ i ng doctri ne is one of absolute responsib i l i ty. Thi s poi n t of view actu a l l y en­ tai l s the comparison of two d i fferent k i nd s of i tems: fi rst, the fixi ng of actions and i ntentions, and second, comparing these actions and i ntentions to some p redetermined criteria of respons i b i l ity. The basic prem i se of the doctr i ne of absol u te respons i b i l i ty is that both actions and i ntentions, on the one hand, and the c riteria of respon sib i l ity, on the other, are absol ute i n that they can be assessed i ndependently of soc ial context.2 An alternative approach fol l ows from the sociology of know l edge. From t h i s p o int of vi ew, the real ity with i n which members of society conduct t h ei r l ives is largely of their own construction.3 S ince much of rea l i ty is a construction, there may be m u ltiple real ities, existing s i de by s ide, in harmony or in com­ petition. It fol lows! if one mainta ins this stance, that the assessment of re­ sponsi b i l ity i nvolves the construction of real ity by members: construction both of actions and i ntentions, on the one hand, and of criteria of responsi b i l i ty, on the other. The former process, the conti nuous reconstruction of the normative order, has long been the focus of sociological concern .4 The d iscussion in th i s chapter i s l i m i ted, for the most part, to the former process, the way i n which actions and i n tentions are constructed i n the act of responsibi l ity. My p u rpose i s to argue that respon si b i l ity i s at l east partly a product of soci al structure. The a l ternative to the doctri ne of absolute respon s i b i li ty i s that of relative responsib i l ity: The assessment of responsib i l i ty al ways i nc l udes a p rocess of negotiation. I n t h i s p rocess, respons i b i l ity i s i n part constructed by the negotiat i ng parties. To i l l ustrate thi s thesis, from two d i alogues of negotiation w i l l be d i scussed : a real psychotherapeutic i n terview and an i nterview between a defense attorney and h i s c l ient, taken from a work of fict i o n . B efore p resenti ng these excerpts, i t is usefu l to review some prior d i scussions of negotiation, the first in cou rts of law, the secon d in medical d iagnos i s . �

Negotiating Reality

117

The negotiation of pleas i n c r i m i nal cou rts, someti mes referred to as "bar­ gai n j u sti ce," has been frequently noted by observers of l ega l processes.6 The defen se attorney or ( i n many cases, apparently) the defendant h i mself strikes a bargai n with the prosecutor-a plea of g u i l ty w i l l be made provi ded that the prosecutor w i l l reduce the charge. For example, a defendant arrested on suspicion of a rmed r obbe r y may a rra nge to p l ead gui l ty to the charge of u n ­ a rmed robbery. T h e prosecutor obta i n s ease o f conviction from t h e barga i n, the defendant, leniency. A l though no expl i ci t estimates are g iven, i t appears from observers' reports that the great majority of criminal convictions are negotiated. Newman ( 1 966) states: A major characteristic of cri m i na l justice adm i n istration. particu larly in j u ris­ d ictions characterized by l eg i s l at ively fixed sentences, is charge reduction to el i c i t p leas of g u i l ty. Not only does the effic ient function i n g of c ri m i na l j ustice rest u pon a h igh proportion of pleas, but p lea barga i n i ng i s l in ked with attempts to i ndividual ize j u stice, to obtai n certa i n desi rable conv i ction consequences, and to avoi d u ndesi rable ones such as "undeserved" mandatory sentences. (p. 76)

It wou l d appear that the barga i n i ng process i s accepted as routine. In the three j urisdictions N ewman studied, there were certai n meeti ng places where the defendant, h i s c l i ent, a nd a representative of the prosecutor's office rou ­ t i n ely m e t t o negotiate the plea. I t seems clear that i n v i rtu a l l y a l l b u t the most u nusual cases, the i nterested parties expected to and actual ly d i d negoti a te the plea. From these comments o n the routine acceptance of p lea barga i ni ng in the courts, one may expect that th i s process woul d be relative l y open and u n ­ a m biguous. Apparently, however, there i s some tension between t h e fact o f b a rga i n i ng a n d mora l expectations concern i n g j u stice. N ewman refers t o thi s tension by citing two contradictory statements: a n actua l j u d i c i a l o pi n ­ ion, "J ustice and l iberty a re no t t h e subj ects o f barga i n i n g and barter"; a nd an off-the-cuff statement by another j udge, "Al l law i s compro m i se." A clea r example of t h i s ten s i on i s provided b y a n excerpt from a tria l and 0.Jewman's com m ents on it: T h e fol lowing questions were asked o f a defendant after he had to u narmed robbery when the origi nal charge was armed tion is common, and the was fu l l y aware that the Judge: Defendant: Judge: Defendant: J udge:

You want to plead gui lty to robbery u narmed? Yes, S i r. Your p lea of gui lty is free and vo l u ntary? Yes, S i r. No one has promi sed you a nyt h i ng?

118 Defendant: Judge: Defendant: Judge: Defendant: Judge:

Negotiating Rea l i ty No. N o one has i nduced you to plead gui lty? No. You're pleading gu i l ty because you are gui lty? Yes. I ' l l accept you r plea of gui lty to robbery unarmed and refer it to the probation department for a report and for sentenci ng Dec. 2 8 . (p. 8 3 )

The del icacy of the relationship between appearance and real ity i s apparently confu s i ng, even for the soc i ologist-observer. Newman's comment on t h i s exchange h a s an A l i ce-i n-Wonderland q u a l i ty: "Th i s i s a routi ne procedu re designed to sati sfy the statutory req u i rement and i s not i ntended to d i sgu i se the process of charge reduction" ( i b i d . ) . If we put the tensions between the d ifferent real ities aside for the moment, we can say that there i s an expl i ci t process of negotiation between t he defendant and t h e prosecution that i s a part of the legal determ i nation of gu i lt or i n nocence or, i n the terms used here, the assessment of respons i b i I ity. In medical d i agnosi s, a s i m i lar process of negotiation occurs but is m uch less self-conscious than plea barga i n i ng. The Engl ish psychoanalyst M ichael Bal i nt ( 1 9 5 7) refers to t h is process as one of "offers and responses" : Some of the people who, for some reason or other, fi nd it d ifficult to cope with problems of their l ives resort to becoming i l l . If the doctor has the opportu nity of seeing them in the fi rst phases of their being i l l, i .e. before they settle down to a definite "organ i zed" i l l ness, he may observe that the patients, so to speak, offer or propose various i l l nesses, and that they have to go on offeri ng new i l l nesses until between doctor and patient an agreement can be reached resulting in the acceptance by both of them of one of the i l l nesses as j ustified. (p. 1 8)

Bal i nt gives n u merous examples i nd i cating that patients propose reasons for their com i ng to the doctor that are rejected, one by one, by the physi ci an, who makes cou nterproposa l s u nt il an " i l l ness" acceptable to both parties i s fou n d . If "defi n ition of t h e s i tuation" i s su bstituted for " i l l ness," Bal i nt's ob­ servations become relevant to a wide variety of transactions, i nc l u d i ng the kind of i nterrogation j u st d i scussed. The fixing of responsi b i l i ty is a process in wh i ch the cl ient offers defi n itions of the s i tuation to which the i nterroga­ tor responds. After a series of offers and responses, a defi n ition of the situation acceptable to both the cl ient and the i nterrogator i s reached. Bal i nt has observed that the negotiation process leads physi ci ans to i nflu­ ence the outcome of medical exa mi nations i ndependently of the patient's cond ition.7 He refers to th i s process as the "aposto l i c function" of the doc­ tor, argu ing that the physician i nduces patients to have the k i n d of i l l ness that the physician t h i nks i s proper:

·

Negotia ting Reality

1 19

Aposto l i c m i ssion or fu nction means i n the first p lace that every doctor has a vague, but a l most u nshakably firm, idea of how a patient ought to behave when i l l . A lthough t h i s i dea is anyt h i ng but explicit and concrete, it is i m­ mensely powerfu l, a nd i nfluences, as we have found, practic a l ly every deta i l of the doctor's work w ith h i s patients. I t was a lmost as i f every doctor had re­ vealed know l edge of what was right and what was wrong for patients to expect and to endu re, and further, as if he had a sacred d uty to convert to h i s faith a l l the ignora nt a n d u n bel iev i ng among h is patients. ( 2 1 6)

I mp l i c i t in thi s statement is the notion that i nterrogator and c l ient have u n ­ equ a l power i n determi n i ng the res u ltant defi n ition o f t h e situation. The i n­ terrogator's defin iti on of the situation p l ays a n i m porta n t part i n the j o i n t defi n ition o f the situation that i s fin a l l y negotiated. Moreover, h i s defin ition i s more i m portant than the c l ient's in determi n i ng the fi n al outcome of the negotiation, p r i n c i pa l l y he i s wel l-tra i ned, secu re, a n d self-confident i n h i s rol e in the transaction, whereas the c l ient is u n tutored, anxious, and u ncerta i n about h i s role. Stated s i m p l y, the subj ect, becau se of these condi ­ tions, is l i ke l y t o b e s uscept i b l e t o t h e i nfluence o f t h e i nterrogator. Note that pl ea barga i n i n g and the p rocess of "offers and responses" i n d i ­ agnosis d i ffer i n t h e degree o f self-consciousness o f t h e part i c i pants. I n plea barga i n i ng, the process is at l east partly visible to the part i c ipants themselves. There appears to be some ambigu i ty about the extent to which the negotia­ tion is moral ly acceptable to some of the commentators, but the parties to the negotiations appear to be aware that barga i n i ng is goi ng on and accept the process as such. The ba rga i n i ng p rocess in d iagnosis, h owever, is m u c h more s ubterranean . Certa i n ly, neither p hysicians nor patients recogni ze the offers and responses process as being barga i n i ng. There is n o commo n l y ac­ cepted vocabu lary for desc r i b i n g d i agnosti c barga i n i ng, such as there is i n the l ega l a n a l ogy "coppi ng out" o r '1copp i ng a p lea" ) . I t m ay be that i n l ega l p rocesses there is some appreciation of the d i fferent k i nds of real i ty [ i.e., the d i fference between the p u b l i c (offic i a l , l egal ) rea l i ty an d p rivate re­ a l i ty] , whereas i n medi c ine, t h i s d i fference is not recogni zed. The d i scussion so far has suggested that m uc h of rea l i ty i s arrived at by ne­ gotiation. Th i s thes i s was i l l ustrated by materials p resented on l egal p rocesses by N ewman and medi ca l p rocesses by Bal i nt. These p rocesses a re s i m i la r i n c lear i nstances of the negotiation of rea l i ty. The that they appear to i nstances are di fferent in that the l egal barga i n i ng p rocesses appear to be more open and accepted than the d iagnostic process. In o rder to outl i ne some of the d imensions of the negotiation p rocess and to estab l ish some of the l i mi ­ tatio n s o f t h e analyses b y Newman a nd Bal i n t, two excerpts o f cases of barga i n i ng w i l l be d i sc ussed: the fi rst is taken from an actua l psychiatric " i n­ take" i nterview, the second from a fictional account of a defense lawyer's fi rst i nterview with h i s c l ient.

1 20

Negotiati ng Rea l i ty THE PROCESS OF NEGOTIATION

The psych i atric i nterview d i scussed is from the fi rst i nterview in G i l l , New­ man, and Red l ich ( 1 954). The patient is a 34-year-old n u rse who fee ls, as she says, " i rritable, tense, depressed." She appears to be sayi n g from the very be­ g i n n i ng of the i nterview that the external situation i n which she l ives is the cause of her troubles. She focu ses particul arly on her h usband's behavior. She says he i s an alcohol ic, i s verba l l y abusive, and won't let her work. She feel s that s h e i s cooped up i n t h e house a l l day w i t h h e r two sma l l ch i ldren, b u t that when he i s home a t n ight ( o n t h e n i ghts when he i s a t home), he w i l l have noth ing t o do w i t h h e r and t h e ch i ldren . S h e i nt i m ates, i n several ways, that he does not serve as a sexual compan io n . She has thought of d ivorce but has rejected i t for various reasons (e.g., she i s afraid she cou l dn 't take proper care of the ch i ldren, fi nance the babysi tters). She feel s trapped.8 I n the con c l u d i ng paragraph of their description of th i s i n terview, G i l l et a l . give th i s summary: The patient, pushed by we know not what or why at the time (the c h i ldren somebody to tal k to) comes for help apparently for what she t h i n ks of as help w ith her externa l s ituation ( her h usband's behavior as she sees it). The therapist does not respond to this but seeks her role and how it is that she plays such a role. Liste n i ng to the record i ng it sounds as if the therapist is at fi rst bored and disinterested and the patient defensive. He gets down to work and keeps ask i ng, "What i s it a l l about?" Then he becomes more i nterested and sympathetic and at the same time very active (participati ng) and demandi ng. It sounds as if she keeps saying " This is the trouble." He says, "No! Tell me the trouble." She says, " This is it! " He says, "No, tell me," un til the pa tient finally says, "Well I 'll tell you." Then the therapist says, "Good! I 'll help you "

(p. 1 3 3 ; ita l ics added)

From t h i s s u m mary, it is apparent that there is a close fit between Bal i nt's idea of the negotiation of d iagnosi s through offers and responses and what took place in th i s psych iatric i nterview. It is d iffic u l t, however, to docu ment the deta i l s. Most of the psychiatrist's responses, rejecti ng the patient's offers, do not appear in the written transcri pt, but they are fai r l y obvious as one l i stens to the recordi ng. Two particu la r features of the psychiatrist's responses espe­ c i a l ly stand out: ( 1 ) the flatness of i ntonation in h i s responses to the patient's complai nts about her external c i rcumstances, and (2 ) the rap i d i ty with wh i ch he introduces new topics, through q uestio n i ng, when she i s tal ki ng about her h usband. Some features of the psych i atrist's coac h i ng are verbal , however: 1.95:

Has anyth ing happened recently that makes it . . . you feel that . . . a h . . . you're sort of coming to the end of your rope? I mean I wondered what led you . . .

The Process of Negotiation

P.95: 1.96: P.96: 1.97: P.97: 1.98: P.98: 1.99: P.99:

1.1 00: P.1 00: 1.1 01 :

P.1 01 : 1. 1 02: P. 1 02: 1.1 03: P.1 03: 1.1 04: P.1 04: 1.1 05: P.1 05: 1.1 06: P.1 06: 1.1 07: P.1 07: 1.1 08:

P.1 08: 1. 1 09:

1 21

(I nterrupting.) It's noth i ng spec i a l . It's j ust everyth i ng in genera l . What led you t o come t o a . . . ( i nterrupti ng) It's j ust that I . . . . . . a psychi atrist j ust now? [ 1 1 Because I felt that the o lder girl was getting tense as a resu l t of . . . of my being stewed up a l l the time. Mmmhnn. N o t hav i ng much patience with her. M m m h n n . (short pause) Mmm. And how had you i magi ned that a psy c h i atrist cou ld help with th is? (short pause) [2 1 Mmm . . . maybe I cou l d sort of get straightened out . . . stra ighten thi ngs out in my own m i nd. I ' m confused. Sometimes I can't remember th i ngs that I've done, whether I 've done 'em or not or whether they happened. What i s it that you want to straighten out? ( Pause) I th i n k I seem m ixed up. Yeah ? You see that, it seems to me, i s somet h i ng that we rea l l y shou ld ta l k about because . . . ah . . . from a certa i n poi nt o f view somebody might say, "We l l now, it's a l l very s i mple. She's u nhappy and d istu rbed because her husband is behaving this way, and u n l ess someth i ng can be done about that how could she expect to feel any other way." But, i n stead of that, you come to the psychiatrist, and you say that you t h i n k there's some th i ng about you that needs straighte n i ng out. [3] I don't qu ite get it. Can you exp l a i n that to me? (short pause) I someti mes wonder if I ' m emotiona l ly grown up. By which you mean what? When you're married you shou ld have one mate. You shou ldn't go around and look at other men. You've been looki ng at other men? I l ook at them, but that's a I I . M m m h n n . What you mean . . . you mean a grown up person shou ld ac cept the marital s i tuation whatever it happens to be? That was the way I was brought up. Yes. (sighs) You t h i n k that wou ld be a sign of emotional matu rity? No. No. So? Wel l , if you rebel aga i nst the laws of society you have to take the con sequences. Yes? And it's j ust that I . . . I ' m not w i l l ing to take the consequences. I . . . I don't t h i n k it's worth it. M m h n n . So in the meanti me then w h i l e you're i n th i s very d i fficult situa­ tion, you find yourself reacting i n a way that you don't l i ke and that you t h i n k is . . . ah . . . damaging to you r c h i l d ren and yourself? Now what can be done about that? (sn iffs; sighs) I dunno. That's why I came to see you . Yes . I w a s j u st wonderi ng what y o u h a d i n m i nd . D i d you th i n k a

1 22

P.1 09:

1.1 1 0: P.1 1 0: 1.1 1 1 : 1.1 1 2: 1.1 1 3: P.1 1 1 :

P. 1 1 2: P. 1 1 3: 1.1 1 4: P.1 1 4: T.1 1 5: P.1 1 5: 1.1 1 6: P. 1 1 6: 1.1 1 6: P.1 1 7:

Negotiating Rea l i ty psyc h i atrist cou l d . . . ah . . . help you face this k i n d of a s ituation c a l m l y and eas i l y and maturely? [4] Is that it? More or less. I need somebody to ta l k to who isn't emotiona l l y i nvolved with the fam i ly. I have a few friends, but I don't l i ke to bore them. I don't think they should know . . . ah . . . all the i ntimate details of what goes on. Yeah ? It becomes food for gossip. Mmmhnn. Yea h . Mmm. Besides they're i n . . . they're emotional ly i nvolved because they're my friends. They tell me not to stand for it, but they don't understand that if I put my foot down it' l l only get stepped on. That he can make it m i serable for me i n other ways . . . . . . which he does. M m m h n n . I n other words, you find yourself i n a situation and don't know how to cope with it real ly. I don't. You'd l i ke to be able to ta l k that through and come to understand i t bet ter and learn how to cope with it or deal with it in some way. Is that right? I 'd l i ke to know how to deal with it more effectively. Yea h . Does that mean you feel convi n ced that the way you're deal i ng with it now . . . There's somet h i ng wrong of cou rse. . . . someth ing wrong with that. M m m h n n . There's someth i ng wrong with it. (pp. 1 76 1 82)

N ote that the therapist rem i nds her four times9 in t h i s short seq uence that she h as come to see a psychiatrist. Since the context of these remi nders i s o n e i n which the patient i s attri buti ng h e r d ifficu lties to an externa l situa­ tion, particularly her hu sband, it seems p l a u s i b l e to hea r these rem i nders as s u btle requests for analysis of her own contributions to her d i fficu lties. T h i s interpretation i s su pported b y the therapist's su bsequent remarks. W h en t h e patient once aga i n descri bes external problems, t h e therapist tries t h e fol ­ lowi ng tack: 1.1 25: P.1 25: 1.1 26: P. 1 26: 1.1 27: P.1 27: 1. 1 28:

I notice that you've used a number of psychiatric terms here and there. Were you spec i a l l y i nterested in that in you r tra i n i ng, or what? Wel l , my great love is psychology. Psychology? Mmmhnn. How much h ave you studied? Oh (sighs) what you have i n your nurse's tra i n i ng, and I've had general psych, c h i l d and adolescent psych, and the abnormal psych. M m m h n n . Wel l , tel l me . . . ah . . . what wou ld you say if you had to explain yourself what is the prob lem?

1 23

A Contrasting Case

P.1 28: 1.1 29:

You don't d i agnose yourself very wel l , at least I don 't. Wel l you can make a stab at it. (pause) (pp. 1 86 1 87)

Th i s therapeutic th rust i s rewarded: the patient gives a long accou nt of her early l i fe that i nd icates a bel ief that she was not "adj u sted" in the past. The i nterview cont i n ues: 1.1 35: P.1 35: 1.1 36: P. 1 36:

1. 1 37: P.1 37: 1.1 38: P.1 38: 1.1 39: P.1 39: 1.1 40:

And what conc l usions do you draw from all this about why you're not adjusting now the way you t h i n k you should? Wel l , I wasn't adj usted then. I feel that I've come a long way, but I don't t h i n k I'm sti l l . . . I sti l l don't feel that I'm adjusted. And you don't regard your husband as being the d i fficu lty? You th i n k it l ies within yourself? Oh he's a d i fficu lty a l l right, but I figure that even . . . ah . . . had . . . if it had been other th i ngs that . . . that this probably this state would've come on me. Oh you do th i n k so? (s ighs.) I don't think he's the sole factor. No. And what are the factors with i n . . . I mean . . . . . . yourself? Oh it's probably remorse for the past, thi ngs I did. L i ke what? (pause) It's l u m pi ng' hard to tel l , h u n h ? (short pause) (pp. 1 92 1 94)

After some parry i ng, the patient tel l s the therapist what he wants to hear. She feel s gu i l ty because she was p regnant by another man when her present h u sband proposed. She cries. The therapist tel l s the patient she needs and w i l l get psych iatric help, and the i nterview ends, the patient sti l l cryi ng. The negotiational aspects of the p rocess are clear: After the patient has spent most of the i n terview bl am in g her current d ifficulties on external c i rcumstances, she tel l s the therapist a deep secret about w h ic h she fee l s i nten sely g u i l ty. The patient, and not the h usband, is at fa ult. The therapist's tone and man ner change abruptly. From bei ng bored, d i stant, and rejecting, he becomes wa rm and sol i ci tous. Through a process of offers and responses, the therapist and patient have, by i m p l i cation, negotiated a shared defin ition of the s i tuation­ the patient, not the h usband, i s responsible.

A CONTRAST I N G CASE

The negotiation process can, of course, proceed on the opposi te premi se, namely that the cl ient is not responsible. An ideal example wou l d be an i n­ terrogation of a c l ient by a ski l led defense l awyer. U nfortu nately, I have been

1 24

Negotiating Rea l i ty

u nable to l ocate a verbati m transcript of a defense lawyer's i n itial i nterview with h i s cl ient. There is ava i l ab le, however, a fictional portraya l of such an i nterview, written by a man with extens ive experience as defense lawyer, p rosecutor, and j udge. The excerpt to fol l ow i s taken from the novel, Anatomy of a Murder (Traver 1 95 8 ) . The defense lawyer, in h i s i n itial contact with his cl ient, briefly questions h i m regard i ng his actions on the n ight of the k i l l i ng. The c l ient states that he d iscovered that the deceased, Barney Q u i l l , had raped h is wife; he then goes on to state that he then left h is wife, fou n d Q u i l l , and shot h i m : " How long d i d you rema i n with you r w ife before you went t o the hotel bar?" " I don't remember." " I think it is i m portant, and I suggest you try." After a pause. "Maybe an hour." "Maybe more?" "Maybe." "Maybe less?" "Maybe." I paused and l it a cigar. I took my time. I had reached a poi nt where a few wrong answers to a few right questions wou ld leave me w ith a c l ient if I took h i s case whose cause was lega l l y defenseless. Either I stopped now and begged off and l et some other l awyer worry over it or I asked him the few fata l questions and let h i m hang h imself. Or e lse, l i ke any smart lawyer, I went i nto the Lecture. I stud ied my man, who sat as i n scrutable as an Arab, del icately fin geri ng his M i ng holder, dainti l y sipping his dark mustache. He apparently d i d not rea l i ze how close I h a d h i m t o adm itti ng that he was g u i lty o f first degree mu rder, that is, that he "feloniously, w i l lfu l ly and of h i s mal ice aforethought did kill and m u rder one Barney Qu i l l ." The man was a sitti ng duck. (p. 43)

The lawyer here rea l i zes that his l i ne of question i ng has come c l ose to fi x i ng the respo n s i b i l ity for the ki l l ing on his c l i ent. He therefore sh ifts h i s ground b y begi n n i ng "the Lecture" : The Lecture is an anc ient device that lawyers use to coach their c l ients so that the c l i ent won't quite know he has been coached and h i s l awyer can sti l l preserve the face saving i l l usion that h e hasn't done any coachi ng. For coach ing c l ients, l i ke robb i ng them, is not only frowned upon, it is downright un ethi cal and bad, very bad. Hence the Lecture, an artful device as old as the l aw itself, and one used constantly by some of the n icest and most eth ical lawyers in the land. "Who, me? I d idn't tel l h i m what to say," the lawyer can l ater com fort h i m self. " I merely explai ned the law, see." It is a good practice to scowl and sh rug here and add virtuously: "That's my duty, isn't it?" . . . "We w i l l now exp lore the absorb i n g subj ect of l egal j ustification or excuse," I said . . . . "We l l , take self-defense," I began. "That's the classic example of j u stifi able hom icide. On the basis of what I've so far heard and read about your case I do not t h i n k we need pause too long over that. Do you?" "Perhaps not," Lieutenant Manion conceded. "We' l l pass it for now." "Let's," I said dryly. "Then there's the defense of habitation, defense of prop erty, and the defense of relatives or friends. Now there are more ram ifications

A Contrasting Case

1 25

to these defenses than a dog has fleas, but we won't explore them now. I've a l ready told you at length why I don't th i n k you can i nvoke the possible de fense of your wife. When you shot Qu i l l her need for defense had passed. It's as s i m ple as that." "Go on," Lieutenant Manion said, frow n i ng. "Then there's the defense of a hom icide comm itted to prevent a felony say you're bei ng robbed ; to prevent the escape of the felon suppose he's get ting away with you r wal let ; or to arrest a felon you've caught up with h i m a n d he's either try i ng to get away o r has actu a l l y escaped." . . . . . . "Go on, then; what are some of the other legal justifications or excuses?" "Then there's the tricky and dubious defense of i ntoxication. Persona l l y I 've never seen it succeed. But s i nce you were not drunk when you shot Q u i l l we sha l l mercifu l l y not dwe l l on that. Or were you?" " I was cold sober. Please go on." "Then fina l l y there's the defense of i nsanity." I paused and spoke abruptly, a i r i ly: "We l l , that j u st about wi nds it up." I arose as though m a k i n g ready to leave. "Te l l me more." "There is no more." I slowly paced up and down the room. "I mean about th i s i nsanity." "Oh, insanity," I said, elaborately su rprised. It was l i ke l u ring a trai ned sea l w ith a herri ng. "Wel l, i nsan ity, where proven, is a complete defense to m u rder. It does not l ega l l y justify the k i l l i ng, l i ke self defense, say, but rather excuses it." The lecturer was hitti ng his stri de. He was a l so on the home stretch. "Our law requ i res that a pun ishable k i l l i ng i n fact, any cri me must be comm i tted by a sapient human bei ng, one capable, as the l aw i nsists, of d i stinguish i ng be tween right and wrong. If a man is i n sane, l ega l l y i n sane, the act of homicide may sti l l be murder but the l aw excuses the perpetrator." Lieutenant Manion was sitti ng erect now, very sti l l and erect. "I see and this th i s perpetrator, what happens to h i m if he shou ld should be excused ?" " U nder Mich igan law l i ke that of many other states if he i s acqu itted of murder on the grounds of i nsan ity it i s provided that he must be sent to a hos pital for the cri m i n a l l y i nsane u n t i l he is pronou nced sane." . . . Then he looked at me. "Maybe," he said, " maybe I was i nsane." . . . Thoughtfu l ly: " H m . . . Why do you say that?" "We l l , I can't rea l l y say," he went on slowly. " 1 1 guess I bl acked out. I can't remember a thing after I saw h i m stand i ng beh ind the bar that n ight until I got back to my tra i ler." "You mean you mean you don't remember shooting h i m?" I shook my head in wonderment. "Yes, that's what I mean." "You don't even remember driving home?" " No." "You don't remember th reate n i n g Ba rney's bartender when he fo l l owed you outside after the shooti ng as the newspaper says you d i d ? " I paused and held my breath. "You don't remember tel l i ng h i m , 'Do you want some, too, B u ster?' ?"

1 26

Negotiating Rea l i ty

The smolderi ng dark eyes flickered ever so l ittle. " N o, not a th i ng." "My, my," I said b l i n king my eyes, contemplating the wonder of it a l l . "Maybe you've got something there." The Lectu re was over; I h ad told my m a n the law; and now he had told me thi ngs that m ight poss i b l y i n voke the defense of i nsan ity. (pp. 46 47, 5 7, 5 8 59, 60)

The negotiation is complete. The ostens i b l y shared defin ition of the situation establ i shed by the negotiation process i s that the defendant was probably not responsible for h i s actions. Let us now compare the two i nterviews. The major s i m i larity between them is their negotiated character: They both take the form of a series of offers and responses that conti n ue un t il an offer (a defi n ition of the situation) i s reached that is acceptable to both parties. The major d ifference between the transac­ tions is that one, the psychotherapeutic i nterview, arrives at an assessment that the cl ient i s responsible; the other, the defense attorney's i n terview, reaches an assessment that the c l ient was not at fau lt ( i .e., not responsible). How can we account for this d ifference in outcome?

D ISCUSSION

Obviously, given any two real cases of negotiation that have di fferent out­ comes, one may construct a reasonable argument that the di fference i s due to the d i fferences between the cases-the fin d i ng of respo n s i b i l ity, i n one case, and lack of responsi b i l i ty, in the other, the o n l y outcomes that are rea­ sonably consonant with the facts of the respective cases. Without rejecti ng this argument, for the sake of d i scussion only, and without c l ai m i ng any k i n d of proof or demonstration, I wish t o present an altern ative argument; that t h e d ifference i n outcome i s largely due t o t h e d ifferences i n tech nique used by the i nterrogators. Th is argument w i l l al low us to suggest some crucial di men­ sions of negotiation processes. The fi rst d i mension, consciousness of the barga i n i ng aspects of the trans­ action, has al ready been mentioned. I n the psychotherapeutic i nterview, the negotiational natu re of the transaction seems not to be artic u l ated by either party. In the lega l i nterview, however, certa i n l y the l awyer, and perhaps to some extent the cl ient as wel l , i s aware of and accepts the s i tuation as one of stri king a ba rgain, rather than as a relentless pu rs u i t of the abso l u te facts of the matter. The d i mension of shared awareness that the defin ition of the s i tuation i s negotiable seems particularly crucial for assessments o f responsib i l ity. I n both i nterviews, there i s an agenda h idden from the cl ient. I n the psycho­ therapeutic i nterview, it is probab ly the psyc hiatric criterion for acceptance

Discussion

1 27

i nto treatment, the criterion of " i nsight." The psychotherapist has probably been trai ned to view patients with " i n s ight i nto their i l l ness" as favorable can­ d idates for psychotherapy (i .e., patients who accept, or can be led to accept, the problems as i nternal, as part of their personal ity, rather than seeing them as caused by external conditions). In the legal i n terview, the agenda that i s u n known to the c l ient i s the lega l struct u re of defenses or j u stifications for ki l l i ng. I n both the legal and psy­ ch iatric cases, the h i dden agenda i s not a s i mple one. Both i nvolve fitt i ng ab­ stract and ambiguous criteria ( i nsight, on the one hand, l egal j ustification, on the other) to a richly specific, concrete case. In the legal i nterview, the lawyer a l most i m med iately broaches th i s h idden agenda; he states clearly and con­ c i se ly the major legal j ustifications for ki l l i ng. In the psych iatric i nterview, the h i dden agenda i s never revealed. The patient's offers during most of the i nterview are rejected or ignored. In the last part of the i nterview, her last offer i s accepted and she i s told that she w i l l be g iven treatment. I n no case are the reasons for these actions artic u lated by either pa rty. The degree of shared awareness i s related to a secon d d i mension, which concerns the format of the conversation . The lega l i nterview began as an i n ­ terrogation but was q uickly sh ifted away from that format when t h e defense lawyer rea l i zed the d i rection i n which the question i ng was leadi ng the cl ient ( i .e., toward a lega l l y u nambiguous ad m i ssion of gu i lt). On the very brink of such an admission, the defense lawyer stopped asking q uestions and started, i nstead, to make statements. He l i sted the pri ncipal legal j usti fications for ki l l ing and, i n response to the clien t 's questions, gave an exp lanation of each of the j u stifications. Th i s sh ift in format put the cl ient, rather than the lawyer, i n control of the crucial aspects of the negotiation. It i s the cl ient, not the lawyer, who is a l l owed to pose the questions, assess the answers for their rel evance to his case and, most cruc i a l l y, to determ in e for h i mself the most advantageous tack to take. Control of the defi n it io n of the s i tuati on-the evocation of the events and i ntentions releva nt to the assessment of the cl ient's respo n s i b i l i ty for the ki l l i ng-was given to the c l ient by the lawyer. The resulti ng c l ient-control led format of negoti ation gives the cl ient a double advantage. I t not only a l l ows the c l ient the benefit of form u lati ng h i s account of actions and i ntentions in the i r most favorable l i ght, i t a l so al lows him to select, out of a d iverse and ambiguous set of normative criteria concern ing ki l l i ng, the criterion that i s most favQrable to h i s own case. Contrast the format of negotiation used by the psychotherapist. The form is consi stently that of i nterrogati o n . The psychotherapist poses the ques­ tions; the patient answers. The psychotherapist then has the answers at h i s d i sposa l . He may approve or d i sapprove, accept o r reject, o r merely ignore them. Th roughout the entire i nterv iew, the psychotherapist i s i n complete control of the situation. With i n t h i s framework, the tactic that the psy­ chotherapist uses is to reject the patient's "offers" that her h u sband is at fa u l t,

1 28

Negotiating Reality

fi rst by ignori ng them, later, and ever more i ns i stently, by lead i ng her to de­ fine the s i tuation as one i n which she is at fau lt. In effect, what the therapist does i s to reject her offers and to make his own counteroffers. These remarks concern ing the re lationship between tech n ique of i nterro­ gation and outcome suggest an approach to assessment of responsibil ity some­ what different from that usual l y fol lowed. The commonsense approach to i n­ terrogation i s to ask how accu rate and fai r i s the outcome. Both Newman's and B a li nt's anal yses of negotiation ra i se this q uestion. Both presuppose that there is an objective state of affai rs that is i ndependent of the tech n ique of assess­ ment. Thi s is q u i te clear in Newman's d iscussion, as he conti nually refers to defendants who are "rea l ly" or "actually" guil ty or i n nocent. 1 0 The s ituation i s less clear i n B a l i nt's d iscussion, although occasionally he i mplies that certai n patients are real l y physica l l y healthy b u t psychological ly d i stressed. The type of analysis suggested by th i s chapter seeks to avoid such presup­ pos i tions. I t can be argued that independently of the facts of the case, the tech n ique of assessment plays a part in determ i n i ng the outcome. In parti c­ u lar, one can avo i d making assumptions about actual respons i b i l i ty by uti­ l i z i ng a tech n i que of textual criticism of a transaction. The key d i mension in such work wou l d be the re lative power and authori ty of the participants in the s i tuation . 1 1 As an i ntroduction to the way i n which power d i fferences between i n ter­ actants shape the outcome of negotiations, let us take as an example an at­ torney in a trial deal i ng with "friendly" and " unfriend l y" witnesses. A friendly w itness i s a person whose testi mony w i l l support the defin ition of the situa­ tion the attorney seeks to convey to the j u ry. With such a witness the attor­ ney does not empl oy power b ut treats h i m as an eq ual . H i s q uestions to such a w itness are open and a llow the witness considerable freedom . The attorney may frame a question such as, "Cou ld you tel l us about you r actions on the n ight of . . . ?" The opposi ng attorney, h owever, i nterested in estab l i s h i ng his own version of the witness's behavior on the same n i ght, wou l d probably approach the task qu ite d i fferently. He may say: "You fel t angry and offended on the n ight of . . . , di dn't you?" The w itness frequently wi l l try to evade so d i rect a ques­ tion with an answer l i ke: "Actua l l y, I had started to . . . " The attorney q u ickly i nterrupts, addressi ng the j udge: "Wi l l the court order the witness to respond to the question, yes or no?" That i s to say, the q uestion posed by the oppos­ i ng attorney is abrupt and d i rect. When the w itness attempts to answer i nd i ­ rectly, a n d a t length, t h e attorney q u ickly invokes t h e power o f t h e cou rt to coerce the witness to answer as he wi shes, d i rectl y. The witness and the at­ torney are not equals in power; the attorney u ses the coercive power of the court to force the w itness to answer i n the man ner des i red. The attorney confronted by an "u nfriendly" w itness wishes to control the format of the i nteraction, so that he can reta i n control of the defi n i tion of

Discussion

1 29

the s i tuation that i s conveyed to the j u ry. It i s much easier for h i m to neutral­ ize an opposi ng defin ition of the situation if he reta i n s control of the i nterro­ gation format in th i s man ner. By a l l ow ing the u nfriendly w itness to respond only by "yes" or "no" to his own verba l l y conveyed account, he can su ppress the ambient deta i l s of the opposing view that may sway the j u ry, and thus mai nta i n an advantage for his defi n ition over that of the witness. In the psych iatric i nterview j u st d i scussed, the psyc h i atrist obviously does not i nvoke a t h i rd party to enforce h i s control of the i nterv iew. B u t to i mpress the patient that she is not to be h i s equal i n the i n terview he does use a de­ vice that is rem i n iscent of the attorney with an u nfriendly witness. The device is to pose abrupt and d i rect questions to the patient's open-ended accounts, i mplying that the patient should answer b riefly and d i rectly; and, th rough that i mpl i cation, the psych i atrist controls the whole transaction. Th roughout most of the interview, the patient seeks to give detai led accou nts of her behavior and her husband's, but the psych i atrist al most i nvariably counters with a d i ­ rect and, t o t h e patient, seem i ngly u n related questi on. The fi rst i n stance of this procedu re occurs at T.6, the psych iatrist aski ng the patient, "What do you do?" She repl ies " I ' m a n u rse, but my h usband won't let me work." Rather than respon d i ng to the l ast part of her answer, which wou ld be expected in conversation between eq uals, the psych i atrist asks an­ other question, changing the su bject: "How old are you?" Th i s pattern con­ t in ues th roughout most of the i nterview. The psych i atrist appears to be trying to teach the patient to fo l low h i s lead. After some 3 0 or 40 exchanges of th i s ki nd, t h e patient apparently learns h e r lesson; s h e cedes control o f t h e trans­ action completely to the therapist, answering b riefly and d i rectly to d i rect questions and elaborati ng only on cue from the therapi st. The therapist thus i mp lements his control of the i n terview not by d i rect coerc ion but by subtle man i p u l ation. A l l of the foregoing d i scussion concerning shared awareness and the for­ mat of the negotiation suggests several propos itions regard i ng control over the defi n ition of the s i tuation. The professional i nterrogator, whether lawyer or psychotherapist, can mai nta i n control if the c l ient cedes control to h i m be­ cause of h i s authority as an expert, because of h i s man i p u l ative ski l l i n the transaction, or merely because the i nterrogator controls access to someth i ng the c l ient wants (e.g., treatment or a lega l excuse). The propositions are: Pro p osition 1 a: Shared a wareness of the participants tha t the situa tion is one of negotiation. (The greater the shared a wareness the more control the client gets over the resultan t definition of the situation. ) Pro p osition 1 b: Explicitness of the agenda . (The more explicit the agenda of the transaction, the more control the client gets over the resulting definition of the situa tion. )

N egotiating Rea l ity

1 30

Proposition 2a:

Organization of the format of the transaction, offers a n d

responses. (The party t o a negotiation who responds, rather than the party who makes the offers, has relatively more power in con trolling the resultan t shared definition o f the situation. ) Proposition 2b:

Counteroffers. (The responding party who makes counter

offers has rela tively more power than the responding party who limits his re sponse to merely accepting or rejecting the offers of the other party. ) Proposition 2c:

Directness of questions and answers. (The more direct the

questions of the interroga tor and the more direct the answers he demands and receives, the more control he has over the resultant definition of the situation. )

These concepts a n d hypotheses are o n l y suggesti ve u n t i l s u c h t i mes as operational defi n itions can be developed. A l though such terms a s offers a n d responses seem t o have an i mmediate appl icabil i ty t o most conversation, i t i s l i kely that a thorough and systematic analysis of any given conversation wou l d show the need for c l early stated criteria of class i nc l usion and exc l u ­ s i on . Perhaps a good p lace for such research woul d b e i n the transactions for assessi ng respons i b i l i ty previously d i scussed. Si nce some 9 0'Yo of a l l c r i m i ­ nal convictions i n t h e Un i ted States are based on gui l ty p leas, t h e extent t o which tech n iq ues o f i n terrogation subtly i nfluence outcomes wou l d have i m­ mediate po l icy i m pl ication. There i s con s i derable ev idence that i nterrogation techn iq ues i nfluence the outcome of psychotherapeutic i nterviews also. Re­ search in both of these areas wou l d probably have i m p l i cations for both the theory and practice of assessing respons i b i l ity.

CONC lUSION: NEGOTIATION IN SOCIAL SCIENCE RESEARCH

More broadl y, the appl i cation of the soc iology of knowledge to the nego­ tiation of real ity has ram ifications that may apply to a l l of soc i a l science. The i n terviewer in a survey or the experi menter i n a social-psychological exper­ i ment i s a l so i nvolved in a t ransaction w i th a cl ient-the respondent or sub­ ject. Studies by Rosenthal ( 1 966) and Friedman ( 1 967) strongly suggest that the findi ngs in such studies are negotiated, and i nfluenced by the format of the studyY' Rosenthal's review of b i as in research suggests that such b i as is produced by a pervasive and subtle p rocess of i nteraction between the i n­ vestigator and h i s source of data. Those errors that arise because of the i nves­ t igator's i nfluence over the subject (the k i n d of i nfluence d iscussed i n t h i s chapter a s arising out o f power d i sparities i n t h e process of negotiation) Rosenthal calls "expectan cy effects." In order for these errors to occ u r, there must be d i rect contac t between the i nvestigator and the subject. to as "observer effects." These are A second kind of b i as Rosenthal errors of perception or reporti ng which do not requ i re that the s u bject be

131

Notes

i nfl uenced by i nvesti gation. Rosenthal's review leads one to surmise that even with techn i ques that are completely u nobtrusive, observer error cou l d b e q u i te large. 1 3 The occu rrence of these two kinds of b ias poses an i nteresti ng d i lemma for the l awyer, psych i atrist, and soc ia l sci entist. The i nvestigator of h u man phenomena i s usual l y i n terested in more than a sequence of events; he wants to know why the events occu rred. Usua l ly t h i s quest for an explanation leads h i m to deal with the motivation of the persons i nvolved. The lawyer, c l i n i­ cian, soci al psychologist, or survey researcher tries to el i ci t motives d i rectly by questioni ng the part ic ipants. But in the process of questioni ng, as previ­ ously suggested, he h i mself becomes i nvolved in the process of negotiation, perhaps s ubtl y i nfl uencing the i nformants t h rough expecta ncy effects. A h i storian, on the other hand, may try to u se docu ments and records to de­ term in e motives. He wou l d certa i n ly avoid expectancy effects in th i s way, but s i n ce he wou ld not elicit motives d i rectly, he m ight find i t necessary to col­ lect and i nterpret various kinds of evidence that are only i n d i rectly related, at best, to determ i ne motives of the participants. Th us, through h i s choice in the select ion and i nterpretation of the i n d i rect evidence, he may be as s u scep­ t i b l e to error as the i nterrogator, su rvey researcher, or experi menta l i st-h i s error bei ng due t o observer effects, however, rather t h a n expectancy effects. The app l i cation of the ideas out l i ned here to soc ial and psychological re­ search needs to be developed. The five propositions suggested may be used, for example, to esti mate the va l id i ty of su rveys using varying degrees of open­ ended ness in the i r i n terview format. If some tech nique cou l d be developed that wou l d yield an i ndependent assessment of val id i ty, it m ight be possi b l e t o demonstrate, a s Aaron Cicourel h a s suggested, t h e more rel i able t h e tech­ n ique, the less val i d the resu lts. The i nfluence of the assessment itself on the phenomena to be assessed ap­ pears to be a ubiquitous process in human affa i rs, whether i n ord i nary dai ly l ife, i n the determi nation of respon s i b i l ity i n lega l or c l i nical i n terrogation, or i n most types of social science research. The sociology of knowledge per­ spective, which suggests that people go through their l ives constructing rea l­ i ty, offers a framework w ith i n which the negotiation of rea l i ty can be seriously and constructively studied. Th is chapter suggests some of the aven ues of the problem that may req u i re further study. The prevalence of the problem in most areas of human concern recommends it to our attention as a substantial field of study, rather than as an i ssue that can be ignored or, alternatively, be taken as the proof that rigorous knowledge of soc ia l affai rs is i mposs ible.

NOTES 1 . The author wishes to acknowledge the help of the fol lowing persons who crit icized earlier drafts: Aaron Cicourel, Donald Cressey, joan Emerson, Erving Coffman,

1 32

Negot 1 atmg Rea l i ty

M i chael Katz, Lew i s Ku rke, Robert Levy, Sohan La l S h a rma, a n d Pa u l Webben . The c h a pter was w r i tten d u r i ng a fe l l ows h i p prov i ded by the Soc i a l Sc i ence I n stitute, U n i vers i ty of Hawa i i .

2.

The doctr i n e o f abso l ute respon s i b i l i ty i s c learly i l l ustrated i n psych 1 atn c a nd

lega l d i sc u s s i o n s of the i ssue of "c n m i na l respo ns i b i l i ty" ( i . e . , the use of menta l i l l ­ ness as a n excuse from c r i m m a l con v i c t i o n ) . An exa m p l e o f the ass u m pt i o n o f ab sol ute c r i teria of respon s i b i l i ty is fo u n d i n the fol l ow i ng q u otat i o n : "The fi n d i ng that someone i s c n m m a l l y respons i b le mea n s to the psych 1 at r i st that the c r i m m a l m u st c h a n ge h i s behav i o r before he can res u m e h i s pos i t 1 o n i n soc i ety. Th1s injunction is

not d1ctated by morality, but so to speak, by reality" (Sachar 1 9 6 3 ; emphas i s added ) . 3 . Cf. Berger a n d L u c k m a n n ( 1 9 6 6 ) . 4.

The c l a s s i c treatment o f t h i s i ss u e i s fou n d 1 n D u rk he i m ( 1 9 1 5 ) .

5.

A soC i ologica l appl i ca t i o n o f the con cept o f negotia tion, i n a d i fferent con

text, 1 s fou n d in Stra uss et al. ( 1 9 6 3 , pp. 1 4 7 1 6 9 ) .

6.

N ewman ( 1 966) reports a stu dy i n t h i s a rea, toget her w 1 t h a rev iew of ea rl ier

work, 1n "The Negot i a ted P l eas," Pa rt 3 of the comp lete work.

7.

A descr i pt i o n of the n egoti ations between patients i n a t u be rc u l os i s sa n i ta r

i u m a n d t he i r p hys i c i a n s i s fou n d i n Roth ( 1 9 6 3 , pp. 4 8 5 9 ) . Obv i o u s l y, some cases a re more s u scept i b l e to negot i at i o n t h a n others . B a l i nt i m p l i es that the great majo nty of cases in med i c a l p ract i ce a re negot i ated . 8.

S i nce th i s i nterv 1 ew 1 s comp lex a n d s u btle, the reader 1s i nv i ted to l i sten to i t

h 1 mself a n d compare h i s con c l u s i o n s w i t h those d i sc u ssed here . The recorded i nter v i ew is ava i l a b l e on the fi rst LP that accompa n i es G i l l , Newma n , and Red l i c h ( 1 9 5 4 ) .

9.

N u m bers i n brackets added .

1 0.

I n h i s foreword, the ed i tor of the ser i es, Fra n k ] . Rem i n gton, com ments o n

one o f t h e s l i ps t h a t occ u rs freq u e n t l y, the "acqu i tta l o f the gu i l ty," not i ng t h at t h 1 s p h rase

IS

contrad i ctory from t h e l ega l po i n t of v i ew. H e goes o n t o s a y t h a t Newman

i s we l l awa re of t h i s but u ses the p h rase as a conven i ence. N eed less to say, both Rem i n gto n 's com ments a n d m i n e can be correct: The p h rase 1 s u sed as a conven i e nce, but i t a l so revea l s the author's p resu ppos i t i o n s .

11.

Berger a n d Luckma n n a l so emphas i ze the ro le of power, but at the soc i eta l

l eve l : "The s uccess of part i c u l a r concept u a l mach i neries 1 s re lated to the power pos sessed by those who operate them . The co nfrontat i o n of a l ternative symbo l i c u n i verses 1 m p l i es a problem o f power-wh i ch o f t h e confl i ct i ng defi n i t i o n s o f rea l i ty w i l l be ' made to stick' 1 n the soc i ety" ( p . 1 00). H a l ey's ( 1 9 5 9 ) d i sc u s s i o n s o f contro l i n psychothera py a re a l so releva n t . See a l so H a ley ( 1 9 69), "The Power Tactics of jesus C h r i st ."

1 2.

Fried m a n , report i n g a series of stu d i es of expecta ncy effects, seeks to p u t

the res u lts w i t h i n a b road soC i o l og i c a l fra mewo r k .

1 3.

C r i t i c s of " rea ct1ve tech n i q ues" often d i s rega rd the p rob l em o f observer ef

fects. See, for exa m p l e, Webb, C a m pbe l l , Schwartz, a n d Sech rest ( 1 9 6 6 ) .

IV TH E EMOT I O NAL/ R E LAT I O NA L WO R L D

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8 A Psychiatric I nterview Alienation between Patien t and Ps ychia trist1

Th i s chapter proposes to enter the emotiona l/relational world by m icroana­ lyzing the detai l s of d i alogue. I describe a model of attunement, the state of the social bond, the process t hrough which i nteractants in the i n terview fa i l to ach ieve j o i n t attention and fee l i ng. Two separate but i nterrelated systems are i nvolved, a system of com m u n i cation that can lead to jo i n t attention, and a system of deference that can lead to the shari ng of feel i n g. Th rough prospec­ tive-retrospective and counterfactua l methods, i nteractants appear to use the resources of an entire soc iety in each moment of the encou nter. Thei r abi l i ty to u nderstand any given moment i n reference to the extended con text i n which it occurs provides the l i nk between the i nd ividual and soci al structure. Soci ety is based on the m i n ute and u nexp l icated events that make up the microwor/d u nderly i ng ord i nary d i scou rse. N ote that the same psyc h i atric i nterview i s used i n t h i s chapter as in Chapter 7 . B ut here, by analyzing non­ verbal cues in addition to the verba l cues u sed in the earl ier chapter, the analysis goes deeper i nto the web of mean i ng and emotion spun between the two actors. My analysis u ncovers a profound al ienation between the psych i­ atrist and the c l i ent, and the shame/rage spi ra l of hel pless anger that both re­ flects and generates the i r al ienation.

1 35

1 36

A Psyc h i atric I nterview SOC IAL ACTION A N D NAT U RA L LAN G UAGE

How are the actions of i n d iv i d u a l s tra n slated i nto recu rr i n g patterns of co l lective behavior? How i s social structure rea l i zed i n the acti ons of i n d i­ viduals? These questions pose an obvious con ceptual problem for the soci al sciences, s i n ce they i nvolve t h e basi c model o f social behavior. Less obvi­ ously, a l so i m p l icated is the methodology of social sc i ence. A l l empi rical re­ search i mpl ies a model of social action, s i n ce it is u lt i mately dependent on observations of i nd ividual behavior. I n the absence of an expl i ci t theory, each researcher is forced to i mprov i se a theory for the case at hand. I claim that the basic h u man bond involves mental and emotional con­ nectedness, that social orga n i zation req u i res what Stern ( 1 985) has cal l ed a t­ tunement between i nd ividuals, the sharing of thoughts and fee l i ngs. Soci ety is possi b l e to the extent that i ts members are able to con nect with each other in this way. Soci ety i s endangered by anarchy to the extent that i nteracti ng members fa i l to fi nd attunement, lack con nectedness, as in the excerpt be low. I i l l ustrate th i s model with findi ngs from recent research, and with a concrete episode of social i nteraction. My starting poi nt is an empirical fi nding from work on artificial i ntel li gence. In the last twenty years an i m portant d iscovery has been made by attempts at automated i nterla nguage translation. No al gorithm has been found that i s sop h i st i cated enough t o trans l ate sentences from o n e natural language to another. To put it in a sl ightly d ifferent way, computers have been u nable to u nderstand natural language sentences, and are u n l i kel y to do so i n the fore­ seeable futu re (Wi nograd 1 984) . As i n d icated ear l ier, words i n natural languages common words have more than one mea n i ng. Consider the sentence: The box i s in the pen . I s pen t o b e understood a s an enclosu re or a s a writing i nstrument? The computer faced with th i s dec ision has recourse only to a d i ctionary. The na­ tive speaker has encyclopedi c knowledge of the mea n i ng of pen, and a l so recourse to contextual know ledge of the sentence i nvolved . Consi derations of the usual si zes, shapes, and u ses of pens and boxes m i ght lead the native speaker to prefer enclosu re as the mea n i ng i n th i s case. Even though th i s i s a relatively s i mple problem (compared w i t h h i g h l y metaphoric sentences) i t wou l d b e extremely ted i ous t o make t h e speaker's decis ion process exp l i c i t for j ust th i s o n e sentence. Even at th i s e l ementary leve l , verba l sentences appear to i nvolve open, rather than closed domai n s. The latter i nvolve a fi n ite n u m ber of objects, choices, and ru les, each of which is u n iq uely defined. The game of tic-tac­ toe provides a si m ple example: there are only two objects, X and 0, and, on the fi rst move, 9 choices. The rules are u n iquely defi ned so that there is no

Social Action and Natural Language

1 37

poss i b i l ity of ambigui ty. Most branches of mathematics i nvolve closed domai ns (e.g., algebra, calcul us). An open doma i n i nvo lves a very large n umber of objects and ru les which are not un iquely defi ned. The abi l ity to function i n an open dom a i n l i ke nat­ u ra l language now appears to be based on extraord i na r i l y com pl ex s k i l l s, which are executed with l ightn i ng-l i ke rap i d i ty. If we move from the arena of sentences composed of words to those that are spoken, with the i r accompa­ n i ment of nonverbal gestures, we may appreci ate the complexity. The amount of i nformation carried by d i gi tal language i s s ma l l compared with that car­ ried by gestures both seen and heard. These gestu res are not d igital, bu t con t in uous; they si gnal vastly more i nformation. F i n d i ngs from conversation and d i scou rse analysis suggest the i mportance of nonverbal gestures i n social i nteraction (Sacks et a l . 1 9 74; Atki nson and Heritage 1 984). To summarize many studies, and extrapolate to expected fu­ ture fi ndi ngs: it wou l d appear that every sentence uttered contains sequencing signals that a l l ow the l i stener to determ ine whether the speaker w i l l conti n ue to speak, or stop at the end of the sentence. Although some of this i nformation is conveyed verbally, most is nonverba l . Pa rticularly i mporta nt is the i ntona­ tion contour of the sentence: the relative speed, loudness and p i tch of the sy l lables that make it up. Sequencing signals al low for rap i d and seem i ngly effortless coord i nation of speech between speakers, a turn-taking system. Th i s finding may constitute the fi rst u n iversal , pan-c u l tural reg u l arity i n l anguage use. Tu rn-taki ng a l so appears to occu r v i rtu a l ly at b i rth i n the i nteraction between caretaker and i nfant (Stern Hofer, Haft, and Dare 1 984; Tro nick, R i cks, and Coh n 1 982). For th i s reason i t i s plausible that the motive and some of the abi I i ty to take turns is geneti ca l l y i n herited. I t wou l d appear that sequencing signals are o n l y a m i n ute part of the so­ c i a l l y relevant i nformation packed i nto a spoken sentence. Tu rn-taking makes up o n l y one sma l l aspect of the deference/emotion system. Coord i nating turns at speaking i s a mechan i ca l problem of avoiding i nterru ption only i n part. I t a l so i nvolves a moral i ssue, the sign a l i ng of status. I n order to show respect, the l i stener must not only avo i d speaking before the speaker has fi n i s hed . There m ust be a decent pause (perhaps one or two seconds) before the l i stener begi ns, show in g that speech has been registered, cons i dered. Even if the l istener's response has no overlap with the last sen­ tence spoken, the absence of the req u is i te pause wi II usual l y be heard as d i srespectfu l . The l i stener m ust a l so avoid too lengthy a pause. A s i lence of more than th ree or fou r seconds w i l l usua l ly be heard as i mp l y i ng di sagreement or con­ fusion, and therefore as possib ly d isrespectfu l . The rhythm of spoken speech is freighted with deference signals. Speaker and l istener m ust both be i nvolved.

1 38

A Psychiatric Interview

In the role of l istener, the i n teractan t must take care to detect a n d honor sequenci ng signals. In the role of speaker, the signal i ng task is much greater. Not o n l y m ust sequencing be signaled, but also the status of the speaker and the l istener(s). For exa mple, speak i n g too rap i d l y and/or with too l i ttle i n to­ nation may be u nderstood as signa l i ng lack of i nterest or respect. S i m i la rl y, speaking too slowly and with too much emphasis and gesti c ulation m ay also be taken as d i s respectfu l of the l istener's a b i l ity to u nderstand. The rhyt h m of speech i s o n l y one of many aven ues for award ing or with­ hold i ng deference. Goffman ( 1 967) proposed that every sentence, i ts words, para l a nguage, and gestures, i m p l y an eval uation of the soci a l and i nterper­ sonal status of the i nteractants: The hu man ten dency to use sign s a n d symbol s means that evidence of soci a l worth a n d o f mutual eva luations w i l l be conveyed by very m i nor thi n gs, and these th i ngs wi II be w i tnessed, as wi II the fact that they have been w i tnessed. An u n guarded glance, a momentary change i n tone o f voice, an ecological position taken or not taken, can d rench a ta l k with judgmental s i g n ificance. Therefore, j ust as there i s no occasi o n of tal k i n w h i ch i m p roper i m p ress ions c o u l d not i ntention a l l y or u n i ntentional l y arise, so there i s no occasi o n of tal k so trivial as not to req u i re each part i c i pant to show serious concern with the way in which he h a n d l es h i mself and the others present. (p. 3 3 )

Goffma n a rgued, furthermore, that a l l i nteractants a r e exqu isitel y sensi tive to the exact amount of deference they a re bei ng awarded. If they beli eve they are receiving too much or, m u ch more frequently, too l i tt l e, they w i l l be em­ barrassed. H i s argument concern i ng embarrassment i ntroduces us i nto the realm of feeling. Before d i sc ussi ng this realm, I once aga i n refer to a secon d system with which the deference system is entangled . Coffman's ana lysis of soci a l i nteraction a lso i m p l ies a nother extremely i n­ tricate system, the system of com m u n i cation that enables i nteractants to u n ­ dersta nd one a nother. Although m i su n de rstan d i ng a l so occu rs, i t i s a lso clea r that i nteractants, at t imes, can understand each other. We a re certa i n that w e have u nderstood others when we learn that w e have correctl y pre­ d icted the i r i ntentions, and they o u rs. For example, an appoi ntment is set u p on one occasion for d i nner on a l ater one. When our partner arrives at the right t i m e and place , dressed as expected, and i n the expected frame of mi nd, i t i s c lear that i nterpretive un­ dersta n d i ng j o i ntly occur red on the earl i e r occasi o n . One has correct l y un­ derstood the other's i ntent, a n i nner phenomenon, by noting outer markers. One h as u n derstood not o n l y the spoken words, but the i nn e r i ntent to whi ch the words referred; as expected, the other was not l y i n g or joki ng. As suggested in the a n a lysis of the excerpt below, the same process of p re­ d i ction and confi rmation can a l so take p lace cont i n uously w i t h i n any given episode.

Example of Interaction Ritual

1 39

Although i nterpretive understandi ng i s so frequent that we take it for granted, it is by no mea ns clear how one " reads another's m i nd." Coffman ( 1 967) care­ fu l l y describes the conditions u nder which successfu l m i n d-readi ng is most l i kely to occur: An u nderstand i ng w i l l preva i l as t o w h e n and where it w i l l b e perm issible to i n itiate ta l k, among whom, and by means of what topics of conversation. A set of s ign i ficant gestures is employed to i n i tiate a spate of comm u n i cation and as a means for the persons concerned to accred it each other as legitima te par ticipants. When this process of reciprocal ra tification occurs, the persons so rat ified are in what m i ght be cal led "a state of tal k" that i s, they have dec lared themselves offic i a l l y open to one another for pu rposes of spoken comm u n ica tion and guarantee together to mai nta i n a flow of words . . . . A single focus of though t and visual atten tion, and a si ngle flow of talk, tends to be mai ntained and to be l egitimated as offic i a l ly representative of the encou nter. (p. 34, em phasis added)

Th i s is a deta i l ed desc ription of the s i tuation in which the " mystic u n ion" of successfu l com m u n i cation is l i kely to occ ur. The concept of legitimacy that Coffman i ntroduces i n t h i s passage serves to bridge the two d i fferent systems, deference and com m u n i catio n . Com m u n i cation occurs most effectively i f the i nteractants "reci procal ly ratify" each other as legiti mate partners i n the com m u n ication enterprise. Such rat ification i s signaled by the v i rtua l l y con­ t i n uous award ing and registering of markers of deference. ( B ru ner 1 983, i n h i s analysis of the ch i l d's acqu isition of la nguage, treats the com m u n i cation system in a way very s i m i lar to Coffman, as the ach ievement of j o i n t atten­ tion, but ma kes no reference to the deference system. ) I t wou l d appear that each uttered sentence i s a dynamic package, loaded with an extraord i n ary amount of i nfo rmation . It may be considered to be analogous to the ce l l i n a l iving organ ism, the smallest system. As Goethe suggested in h i s d i scussion of morphogenesis, it may be necessary to u nder­ stand the structure of the cel l i n order to u nderstand the organ ism, and the structu re of the orga n i s m in order to u nderstand the cel l . In the proposed model, soc iety exi sts to the extent that its members are able to ach ieve at­ tunement, the sharing of mea n i ngs and fee l i ngs.

EXAMPLE OF I NTERACTION RITUAL: T H E OPEN I N G EXC H A N G E I N A CONVERSATION

Coffman's analysis i s so dense and abstract that i t i s d ifficult to know whether we u nderstan d h i s mea n i ng. I n t h i s sectio n I show, i n a concrete example, the markers of deference and com m u n i cation that suggest the ex­ i stence of two d i sti nct but i nterrelated systems. The analysis of th i s example

1 40

A Psych iatric I nterview

w i l l be used to descr i be exchanges of feel ing, and the methods interactants (and researchers) u se when they a re i nterpreting events. The passage comes from a widely known psych iatric i nterview ( G i l l et a l . 1 954). It was the basis for a subsequent study (Pittenger, Hockett, and Danehy 1 960). Because the original work was accom p a n i ed by a long-playing record, Pittenger and h i s col leagues were able to conduct a m icroscop i c study of the verbal and nonverba l events in the fi rst five m i n utes of the i nterview. My analysis of the ope n i ng exchange i s based upon and further develops that of P i ttenger, Hockett, and Danehy ( 1 9 60). In partic ular, I use tech ni ques i m p l ied in thei r work, and that of Labov and Fanshel ( 1 977) and Lewis { 1 9 7 1 ), to i n­ terpret the message stack. That i s, I uti l ize the words i n the t ranscript and the nonverbal sounds in the recordi ng to i n fer the u nstated i m p l ications (the implicature) a n d feelings that u nderl i e the d i alogue. ( For a more detai led d is­ cussion, see Scheff 1 98 9 . ) It beg i n s with the therapist (T) and the patient (P) e nter i ng the i nterv i ew i n g room: Tl : Pl : T2 : P2: T3: P3: T4: P4: TS:

W i l l you s i t there. (soft l y l {sits dow n ) ( c l oses doors) What b r ings you here? ( s i ts down) Everyt h i ng's wrong I guess. I rrita b l e, tense, depressed. (Sighs\ ) us' . . . just everythi ng a n d everybody gets on my nerves. Nyea h . I don't feel l i ke ta l ki n g r ight now. You don't? (short pause) Do you somet i mes? That's the troub l e . I get too wou n d up. If I get started I ' m a l l r i g ht. N yea h ? Wel l perhaps you w i l l .

puzzles. For example, a A close rea d i n g o f t h i s passage suggests pause of eight seconds occu rs i n T 4. As a l ready noted, a pause of more than two seconds i s l i ke l y to make i n teractants uncomfortable. In seeking to un­ derstand why the patient d idn't respond to the first part T 4, we notice her precedi ng comment ( P3 ) : "I don't feel l i ke talking right now." Why wou l d the patient not feel l i ke ta lking when less than a minute has elapsed in the i nter­ v i ew? I suggest a n a n swer to t h i s question to i l l ustrate Pittenger et al .'s ( 1 960) methods and fi ndi ngs, and my elaboration of them. Pittenger et al .'s analysis of the l a nguage and para l anguage in th i s passage suggests that fai l ure of attunement occurred d u r i ng the first th ree exchanges, resulting i n a crisis after T 4a. Thi s crisis seems rectified after T 4b. The i r analy­ s i s of the rest of the f i rst five m i nutes, however, and m ine of the rest of the i nterview, suggest that the crisis was averted only temporari ly; the i nterac­ tants a re i nadequatel y attu ned for most of the i ntervi ew. My a nalysis w i l l be used to i l l ustrate the i nterdependence of the systems of com m u n ication and deference. I n this i n stance, the crisis i nvolved both m i s understand i ng and a n exchange o f pai nfu l fee l i ngs.

Embarrassment and Anger

1 41

P i ttenger et a l . ( 1 960) suggest that a m i s u n dersta n d i ng occ urred at T4a because of T's choice of words and i ntonations in h i s fi rst th ree utterances. A l most a l l of the words chosen are "pronom i n a l s," b l a n k checks, and the i ntonations are "opaque," i .e., flat. P must have heard these utterances, they say, as i nd i cative of detach ment, boredom, and d i s i n terest: * " Here we go aga i n ! How many ti mes have I heard this k i n d of th i n g ! "2 Although u nstated, these sentences are i m p l ied by the choice of words and i ntonations, part of the structure of com m u n i cation that I refer to as i m p l icatu re. The authors go on to argue that P has mi su nderstood at least T's intent, if not h i s actual behavior. They say that he d i d n't i ntend to signal detachment, but neutral i ty: *"You can tel l me anyth i ng without fear of condemnation." The authors argue that d u ri n g the si lence after T4a, T m ust have rea l i zed that P had heard h i m as cold and detached, because i n T 4b, for the first ti me, he uses "normal" i ntonations, i .e., he signal s warmth and i n terest. (Perhaps he a l so leans forward sl ightly i n h i s chair, and for the first ti me, s m i les.) T's u ndersta n d i ng of P's mental state i s apparent ly confi rmed by P4: she resumes ta l k i ng. To appreciate the sign ificance of P4, it wi l l be necessary to refer aga i n to the rhythm of turn-taking. P responds to T4 ("You don't?") with an eight-second s i l ence. She does not say *" No, I don't," or its eq uivalent, signa l i ng that she is sti l l i nvolved. Her si lence suggests, rather, that she has withdrawn. Conversation is l i ke a Pi ng-Pong game. P has put her paddle down on the tab le, seated herself, and folded her arms. "If you want me to pl ay th is game, B uster, you better show me somet h i ng different t h an what I have seen so far." I n T4b, T gets the message, and is rewarded with P4. In T5a, however, " Nyea h ?" he seems to forget what he j ust learned, si nce it is del ivered with­ out i ntonation. Th i s ti me, however, a si lence from P of only 1 .8 seconds is necessary to rem i nd hi m : T5b i s del ivered w i t h normal i ntonation. Another confirmation of the authors' i nterpretation is suggested by their analysis of the para la nguage of P3 and P4. They say that P seems u pset i n P3 , but not upset i n P4. S i nce the issue of emotional u pset wi l l be crucial for my argument, I review and elaborate upon their comments. EMBARRASSMENT AND A N G E R: THE FEELI NG TRAP OF SHAME-RAGE

Pittenger et a l . ( 1 960) interp ret the para language of P3 as in d icative of em barrassment on the patient's part:

Th is is a momentary withdrawa l of P from the situation i nto embarrassment w ith overtones of c h i l d ishness . . . [as signa led by [ the sl ight oversoft, the breath i ness, the s loppi ness of articu lation, and the i ncip ient embarrassed giggle on the first sy l l able of talking. ( 1 960, p. 30)

1 42

A Psych iatric I nterview

Pittenger et a l . frequently i nfer embarrassment in P's utterances, as wel l as i rritation, an noyance, or exasperation. As was the case with the therapist, however, these phenomena do not figure p romi nently i n t he i r concerns, but are only mentioned in passi ng. The same th i ng i s true of the analysis of emo­ tion that occurs i n Labov and Fanshel ( 1 9 77), even though the i r analysis is much more sop h i sticated; for example, they note that signs of the compound emotion "helpless anger" appear very frequently i n the patient's para language. Si nce no exp li c i t theory of the role of emotions i n behavior was ava i lable to them, these authors made l i ttle u se of thei r fin d i ngs concerning the emotional states of thei r subjects. In my analysis, however, their references to emotional states w i l l play a central role. As i nd i cated i n ear l ier chapters, I draw u pon the work of Goff­ man and Lewis to u nderstand the excha nges of fee l i ng that seem to take p lace in this interview. I w i l l a l so ca ll upon a grap h i c depiction of soc ial a n d psy­ chological process. Kel l y et a l . ( 1 983) offer a flowchart of processes that take p lace both with i n and between i nteractants, which they cal l "meshed i ntrachai n sequences." Th is model can be used to depict a theory of social action. The basic h u man bond i nvol ves both com m u n ication a n d deference, exchanges of thoughts and fee l i ngs. It w i l l encompass u nderstanding and misu ndersta n d i ng, on the one hand, and l ove and hatred, on the other. Interpretive u nderstand i ng ( verstehen) i nvolves a p rocess between and with i n interactants that was referred to by G. H . Mead (1 934) as " role-taki ng." He s uggested that each party coul d, under ideal conditions, come very c lose to sharing the i n ner experience of the other party. By cycl i n g between ob serving the outer behav i o r of the other a n d imagining the other's i nner expe­ rience, a process of successive approxi mation, i ntersubjective understandi ng, can occur. Peirce [ 1 896� 1 908] used the term "abduction" when desc r i b i ng a s i m ilar process i n scientists. Scientific d iscovery, he argued, i nvolves neither i nduction (observation) nor deduction (i magination) alone, but a very rapid shutt l i n g between the two. Thi s shuttli ng process can by easi ly depicted u s i ng the Kel l y et a l . model. L i ke Coffma n's analys i s, the formu l ations concer n i ng ver.stehen by O i l­ they, Mead, Pei rce, and others have been so abstract a n d dense that i t i s d i f­ fic u l t to find out i f they are useful o r not. Because they offer n o app l i cations to concrete epi sodes, the i r i deas have remai ned somewhat mysterious. Bru ner's ( 1 9 8 3 ) work on the acquisition of language is much more con­ crete