The Sociological Study of Mental Illness: A Historical

Perspective
madinamerica.com/2016/07/the-sociological-study-of-mental-illness-a-historical-perspective/

July 20, 2016

By
Andrew Scull, PhD
Andrew Scull, PhD
-

July 20, 2016

Mental illness, as the eminent historian of psychiatry Michael MacDonald once aptly
remarked, “is the most solitary of afflictions to the people who experience it; but it is the
most social of maladies to those who observe its effects” (MacDonald 1981: 1). It is
precisely the many social and cultural dimensions of mental illness, of course, that have
made the subject of such compelling interest to sociologists. They have responded in a
huge variety of ways to the enormously wide social ramifications of mental illness, and the
inextricable ways in which the cultural and the social are implicated in what some might
view as a purely intrapsychic phenomenon. If psychiatry has typically, though far from
always, focused on the individual who suffers from various forms of mental disorder, for
the sociologist, it is naturally the social aspects and implications of mental disturbance for
the individual, for his or her immediate interactional circle, for the surrounding community,
and for society as a whole, that have been the primary intellectual puzzles that have drawn
attention.

How, for example, are we to define and draw boundaries around mental illness, and to
distinguish it from eccentricity or mere idiosyncrasy, to draw the line between madness
and malingering, mental disturbance and religious inspiration? Who has social warrant to
make such decisions, and why? Do such things vary temporally and cross-culturally? How
have societies responded to the presence of those who do not seem to share our
commonsense notions of reality? Who embrace views of reality that strike others as
delusional? Who see objects and hear voices invisible and inaudible to the rest of us? Who
commit heinous offenses against law and morality with seeming indifference? Or whose
mental life seems so denuded and lacking in substance as to cast doubt on their status as
autonomous human actors?

Mental illness has profoundly disruptive effects on individual lives and on the social order
we all take for granted. Erving Goffman, whose mid-twentieth century writings still
constitute some of the most provocative and profound sociological meditations on the
subject is perhaps best-known for his searing critique of mental hospitals as total
institutions, engines of degradation and destruction that falsely put on a medical gloss
(Goffman 1961). But he also spoke eloquently of “the social significance of the confusion
[the mental patient] creates,” arguing that it “may be as profound and basic as social
existence can get.” He insisted, rightly in my view, that “Mental symptoms are not, by and
large, incidentally a social infraction. By and large, they are specifically and pointedly
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offensive…It follows that if the patient persists in his [sic] symptomatic behavior, then must
create organizational havoc and havoc in the minds of members [of society].”
Characteristically, Goffman then proceeded to critique the response of our contemporary
credentialed experts in the treatment of mental illness” “It is this havoc that psychiatrists
have dismally failed to examine.” But he was equally scathing about many of his
contemporaries in the sociological profession, who then sought to dismiss mental illness
as a purely socially constructed category, a mere matter of labels. For sociologists who
adopted this romantic view were equally guilty of playing down or ignoring the profoundly
disruptive effects of madness on the individual and on society. (See Goffman 1971: 356-
357.)

Accepting, then, that there is such a thing as mental illness (all the while acknowledging
that some sociologists and even some renegade psychiatrists have questioned its reality,
and still others have debated its designation as a specifically medical problem), a whole
series of further questions then arise: How much of it is there, and how do we know, if
indeed we do? What is its social location? Does that differ by class, by age, by gender, by
race, by ethnicity, and so forth? Do these social variables have implications for the way
mental illness is reacted to and socially managed? What are the costs of such episodes of
mental disturbance to individuals, families, and society as a whole, and how are those
costs distributed? How have societies characteristically responded to mental illness, and
what institutions have they constructed to contain and perhaps cure it? What changes in
these responses have occurred over time, and what accounts for these changes? How has
mental illness been conceptualized by professionals, but also by the laity? And how have
these differing cultural meanings been captured, refracted, and distorted in popular
culture? One could go on, and the body of this encyclopedia deals with an even broader
array of sociologically relevant topics, but the vital importance of a sociological perspective
on mental illness should by now be apparent.

It should come as no surprise to learn, then, that from the discipline’s first days, many
sociologists have had something to say about the subject. Sociology as a discipline began
to coalesce in the late nineteenth and early twentieth centuries in France, in Britain, in
Germany, and the United States, at first often outside university settings, as in the British
social survey tradition pioneered by Charles Booth (1889, 1891, 1892-1897) and Benjamin
Seebohm Rowntree (1901), but soon enough within the walls of academic institutions. The
earliest academic sociologists often secured niches in other disciplines – Durkheim’s first
appointment at Bordeaux was in Social Science and Pedagogy and his later chair at the
Sorbonne was as Professor of Education; and Weber’s at Freiburg was in Economics, as
was his next appointment at Heidelberg, but soon enough the discipline managed to
institutionalize itself as a separate and legitimate academic endeavor.

Durkheim played a critical role in this process in France, and aggressively sought to claim
for sociology a distinctive realm of social facts, external and constraining on the individual.
Much of his work thus had an overtly polemical cast, and even the subject matter he chose
was often influenced by its value in establishing the intellectual legitimacy of sociology and
its status as a distinct and autonomous science, and in demonstrating the unique power of
“the social” in the explanation of sociological phenomena. “Every time,” he boldly and
wrongly proclaimed, “a social phenomenon is directly explained by a psychological
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phenomenon, we may rest assured that the explanation is false” (Durkheim 1895: 129).
Two years later, he deliberately chose an apparently quintessentially individual act, suicide,
and attempted to account for it in social terms. More precisely, he claimed to detect in the
statistics on suicide a whole series of distinct regularities, and it was these regularities in
suicide rates for which he proffered a sociological explanation (Durkheim 1897).
Necessarily, he was thereby led to confront the question of insanity and its possible
relationship to suicide – mental illness in both its most florid manifestations and in
borderline examples of mental disturbance such as alcoholism and what was then called
neurasthenia or weakness of the nerves. To his own satisfaction, at least, Durkheim
claimed to have shown that while all of these conditions might predispose an individual
towards suicide, it was social factors rather than individual psychopathology that explained
the rate at which people killed themselves. To the extent that socio-psychological states
led vulnerable people to commit suicide, those states were themselves the product of
sociological factors – in modern societies, most commonly the condition he labeled
“anomie,” or the failure of the social order to regulate adequately the beliefs and behaviors
of its members. (For critiques of Durkheim’s arguments, see Douglas 1967; Lukes 1973.)

If Durkheim and the Durkheimian school dealt with mental illness only tangentially, another
major school of sociological thought that was emerging in the early twentieth century, the
Chicago School led by Park and Burgess frequently tackled the subject more directly. In
important ways, the sociologists trained at the University of Chicago were heirs to the
social survey tradition that had emerged in late nineteenth century Britain. Park, Burgess
and their students treated the city as their laboratory, and set forth to document its
structures and its pathologies (Park, Burgess and McKenzie 1925). Like their British
predecessors, the Chicago sociologists employed both statistical techniques and
ethnographic observation, both mapping the statistical distribution of social problems and
providing detailed ethnographic studies of their place in specific neighborhoods in the city.
Psychoses were only one of a number of what they termed social pathologies that fell
under their gaze – alongside homelessness, alcoholism, suicide, homicide, prostitution,
juvenile delinquency, and crime. Characteristically, the psychological disorganization that
characterizes mental illness (and other forms of deviance) was linked to the social
disorganization of particular communities – the prevalence of anonymous and transitory
social relationships and the weakness of social ties, all associated with the breakdown of
social controls. (For discussions of the Chicago School, see Bulmer 1984; Faris 1967.)
The culmination of this perspective on the sociological study of mental illness came with
the publication in 1939 of Faris and Dunham’s monograph on Mental Disorders in Urban
Areas, a volume which, its title notwithstanding, focused primarily on Chicago See Faris
and Dunham 1939; and for an attempt to generalize their findings to other cities, Schroeder
1942). But in a broader sense, the fascination with deviance that the Chicago School
exhibited, and the preoccupation of many of the sociologists it trained with ethnographic
approaches to the study of social life can be traced in many of the works of post-war
American sociology, not least many of the classic studies that emerged in the 1950s and
1960s devoted to the sociology of mental illness.

The Second World War and its aftermath marked a turning point for American social
science, as for American universities more broadly. The mobilization of society for total
war broke down the barriers – legal and ideological- to the expansion of central state
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powers, as well as finally vanquishing the Great Depression. The upshot was a vast
increase in the size and reach of the American federal government, a development that
proved permanent and that has only accelerated in the years since. In war’s shadow, there
was little disposition to rein in the expanded scope of federal authority, and what resistance
there was melted away with the outbreak of the Cold War in 1947.

Science, including social science, had played an enormous part in the war effort, and as the
conflict drew to a close, efforts were made to rethink the role of science and society in the
soon-to-be post-war world. The most notable instance of this new thinking was Vannevar
Baush’s extended memorandum to President Roosevelt, subsequently published as
Science: The Endless Frontier (Bush 1945). Written by the wartime director of the Office of
Scientific Research and Development, it presented a wide-ranging overview of the
conditions of scientific research, its potential contributions to public welfare, the
reconfigerations that would be necessary after the war, and the potential role of
Washington, both in securing the training of scientific talent, and in the prosecution of
scientific research. Though its primary remit was the natural sciences and medicine, it
ranged broadly over its chosen terrain, and in the Truman administration it would serve as
the inspiration for the formation of the National Science Foundation, and the National
Institutes of Health, both of which would transform the environment for research and the
nature of the modern university. The era of Big Science and the modern research university
may be said to be its progeny. Where before the war, federal involvement in scientific and
medical research, let alone the social sciences, had been vanishingly small, from the late
1940s onwards, and particularly once the Cold War broke out, it started down the pathway
of exponential growth that has continued ever since. With burgeoning federal investment,
the process of knowledge creation and major characteristics of the academic world were
irrevocably altered.

Military conflict had an even more direct impact on the psychiatric sector. Modern
industrialized and mechanized warfare has repeatedly had drastic effects on the mental
health of military personnel, and the Second World War, like the first, saw a massive
number of psychiatric casualties spawned by the horrors of combat. Many of these were
permanently harmed, so that the military authorities faced the immediate emergency of
coping with soldiers breaking down – the effects on fighting efficiency and morale – and
the post-war problems posed by disabled veterans with grave and continuing psychiatric
problems. The exigencies of wartime prompted a massive expansion in the number of
medics deployed to deal with psychiatric emergencies, and a continuing expanded demand
for psychiatrists after the war ended. The knowledge that, under enormous stress, even
the apparently psychiatrically healthy broke down in large numbers, and the heroic status of
these psychiatric casualties, also helped change popular attitudes to mental illness, and
encouraged the psychiatric profession to believe that many cases of mental illness could
be treated outside the walls of the mental hospitals to which the mentally ill had been
traditionally sent (Scull 2010).

The consequences of this situation were many. Direct provision of mental health services
remained a state rather than a federal responsibility, with the exception of a considerable
increase in the number of veterans’ hospitals devoted to providing psychiatric services. But
both the Veterans’ Administration and the newly established National Institute of Mental
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Health were soon pouring funds into the training of mental health professionals, and NIMH
also embarked on a program of basic research in the mental health sector. Within
psychiatry itself, a rapid shift occurred in the locus of psychiatric practice, as more and
more professionals opted for the out-patient sector and the traditional mental hospitals
were left with the dregs of the profession. The number of psychiatrists rose rapidly, and for
at least a quarter century, the most ambitious amongst them for the most part embraced
some version of Freudian psychoanalysis.

NIMH adopted an extremely broad definition of what constituted research relevant to its
mission of understanding mental illness and improving its treatment. Indeed, the bulk of
its research funding was directed to the social sciences, not to psychiatry, in part because
psychoanalysts spurned the sort of research the agency was willing to fund, and in part
because they were such unadept grantsmen. Though the great bulk of the social science
funding went in turn to the discipline of psychology, a not inconsiderable fraction of the
federal moneys were captured by sociologists, and for the three decades after the Second
World War, much of the flourishing state of the sociology of mental illness can be attributed
to this flow of federal research dollars (Scull 2011a; 2011b).

Some of this work was conducted intramurally, at the Laboratory of Socio-Environmental

Studies headed by the sociologist John Clausen (1956), and at the Biometry branch, where
the collection of systematic statistical data and the development of epidemiological
research were encouraged. But much also took the form of NIMH training grants, and
extramural research grants. Substantively, much of the work in the 1950s built upon the
intellectual foundations provided by the Chicago School, in its dual emphasis on
quantitative and ethnographic techniques. Large-scale studies of social class and mental
illness, of mental illness and the family, and of popular conceptions of mental illness were
undertaken, and in some instances stretched over several decades. The centrality of the
mental hospital in the mental health sector both pre- and postwar, and the relevance of
sociological perspectives for the understanding of these complex organizations meant that
these too became a focus of much funded research.

In the early 1950s, much of this research was collaborative in nature, linking together
psychiatrists or other mental health professionals and sociologists in a common
endeavor. Notable examples include Stanton and Schwartz’s (1954) ethnography of the
Chesnut Lodge private mental hospital, and the work by Hollingshead and Redlich (1958)
and their team of researchers on social class and on family dynamics and mental illness
(Myers and Roberts 1959; see also Leighton, Clausen and Wilson 1957; Rennie and Srole
1956; Greenblatt, Levinson and Williams (1957); Yarrow, Schwartz, Murphy and Deasy
(1955)). Soon, however, sociological work began to embrace a far more critical stance
towards psychiatry and psychiatric institutions, a shift in intellectual perspective that
emerged particularly strongly in studies of mental hospitals and of institutional psychiatry.

The altered intellectual stance was evident as early as 1956, with the appearance of Ivan
Belknap’s study of a Texas mental hospital, with its conclusion that “mental hospitals are
probably themselves obstacles in the development of an effective plan of treatment for the
mentally ill” so that “in the long run the abandonment of the state hospitals might be once
of the greatest humanitarian reforms and the greatest financial economy ever achieved”
(Belknap 1956: xi, 212). It is equally evident in such later works as Dunham and Weinberg
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(195 ) and Perrucci (197 ), and perhaps achieved its apotheosis in Erving Goffman’s
devastating portrait of mental hospitals as “total institutions,” which was published in 1961
and became one of the more enduring works of mid-twentieth century American sociology
(Goffman 1961).

Goffman was trained at Chicago, and his research for Asylums, undertaken while he was
on staff at the NIHM Laboratory of Socio-Environmental Studies, included a year of
fieldwork at St Elizabeth’s Mental Hospital in Washington, D.C. But while in one sense
rooted in the Chicago School tradition, Goffman’s work was in many ways Durkheimian in
inspiration. In contrast to the symbolic-interactionist emphasis on the fluidity of social
interaction, Goffman’s is a portrait of structural determinism. Mental hospitals resemble
prisons and concentration camps, as well as monasteries, nunneries, and boarding
schools. Life in such places is a product of their structural features, and their defects are
not removable by any conceivable sets of reforms. Instead, life in a mental hospital tends
inexorably to damage, to dehumanize, and to destroy. Psychiatrists are ridiculed as
members of a “tinkering trade” who induce their subordinates to stage elaborate rituals
designed to show that they preside over a medical establishment devoted to humane care
and cure, when in reality, they are little better than prison guards helping to generate the
very pathologies they claim to treat. As he put it a decade later, mental hospitals were no
more than “hopeless storage dumps trimmed in psychiatric paper.” As for the patient, he
has been duped, suffering “dislocation from civil life, alienation from loved ones who
arranged for the commitment, mortification due to hospital regimentation and surveillance,
permanent post-hospital stigmatization. This has not merely been a bad deal; it has been a
grotesque one” (Goffman 1971: 390).

From the late nineteen-sixties through the nineteen-eighties, the intellectual distance and
even hostility between sociologists and psychiatrists often seemed to be growing. Within
five years of the appearance of Asylums, the California sociologist Thomas Scheff had
authored an in some ways still more radical assault on psychiatry, dismissing the medical
model of mental illness and attempting to replace it with a societal reaction model, wherein
mental patients were portrayed as victims – victims, most obviously, of psychiatrists
(Scheff 1966). Noting that despite centuries of effort, “there is no rigorous knowledge of
the cause, cure, or even the symptoms of functional mental disorders”, he argued that we
would be better off adopting “a [sociological] theory of mental disorder in which psychiatric
symptoms are considered to be labeled violations of social norms, and stable ‘mental
illness’ to be a social role.” And “societal reaction [not internal pathology] is usually the
most important determinant of entry into that role” (Scheff 1966: 7, 25, 28).

During the 1960s and 1970s, the societal reaction theory of deviance enjoyed a broad
popularity and acceptance among many sociologists, and Scheff’s was one of the principal
works in that tradition. But besides attracting derision and hostility from psychiatrists
(Roth 1973), where they deigned to notice his work at all, it came under increasing criticism
from within sociology on both theoretical (Morgan 1975) and empirical (Gove 1970; Gove
and Howell 1974) grounds. In the face of an avalanche of well-founded objections, Scheff
was eventually forced to back away from many of his more extreme positions, and by the
time the third edition of his book appeared (Scheff 1999), most of its bolder ideas had been

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quietly abandoned. Labeling and stigmatization of the mentally ill have remained important
subjects for sociologists, even if few would now argue that they have the etiological
significance once attributed to them.

Though the skeptical claims of the labeling theorists have now been sharply curtailed,
much of the sociological work being done on mental illness has retained its critical edge.
Four major inter-related changes have occurred in the psychiatric sector in the past half
century or so: the progessive abandonment of the prior commitment to segregative
responses to serious mental illness, and the rundown of the state hospital sector; the
collapse of psychoanalysis and its replacement by a renewed emphasis on the biological
basis of mental illness; the psychopharmacological revolution; and the so-called neo-
Kraepelinian revolution, the rise of the American Psychiatric Association’s Diagnostic and
Statistical Manual to a position of overwhelming importance, not just to the practice of
psychiatry in the United States, but to developments elsewhere in the world. Sociologists
have played a crucial role in analyzing the sources and the impact of most of these
changes, and sociological perspectives have spread and been highly influential among
others attempting to make sense of these profoundly important developments.

Deinstitutionalization, for example, was initially presented as a grand reform, ironically just
as the mental hospital had originally been (Rothman 1971; Scull 1979, 1993). From the
mid-nineteen-seventies, however, a more skeptical set of perspectives emerged.
Psychiatrists had assumed that the new generation of anti-psychotic drugs had been the
main drivers of the expulsion of state hospital patients. A series of studies demonstrated
the fallacy of this claim (Scull 1976, 1977; Lerman 1982; Gronfein 1985a). Others sought
alternative explanations of the shift in social policy, and a series of studies began to
suggest some of the defects of the new approach to the management of chronic mental
illness (Kirk and Thierren 1975; Aviram, Syme and Cohen 1976; Windle and Scully 1976;
Scull 1977, 1984; Rose 1979; Gronfein 1985b). The hegemony of the Diagnostic and
Statistical Manual (DSM) began to attract attention, with critics examining both the
processes by which the successive editions had been produced, and the intended and
unintended effects of its widespread use (Kirk and Kutchins 1992; Kutchins 1997; Horwitz
and Wakefield 2007; 2012) The sources and the impact of the psychopharmacological
revolution drew increased interest, with attention paid to both the role of the
pharmaceutical industry and changes in the intellectual orientation of the psychiatric
profession (Healy 1997, 2002; Herzberg 2008).

All of this occurred in a context where much of the federal money which had once
underwritten sociological work on mental illness had been sharply curtailed. In the
nineteen-sixties and seventies, NIMH continued to define its research mission broadly, and
to fund an extensive array of psychological and sociological research. Subjected to
political pressures to direct funding towards the solution of social problems, the agency
underwrote a broad array of studies on such topics as crime, drug and alcohol addiction,
suicide, and even rape – all topics of some relevance to mental health issues, and all
ensuring a continual flow of federal research money into the social sciences, but scarcely
central concerns for those focused on psychiatric disorders. During the 1980s, however,
this pattern of research funding abruptly altered. The Republican administration elected in
1982 ordered NIMH to redirect its funding priorities away from social-problem oriented
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research towards work more directly pertinent to the understanding of mental disorders
(Kolb, Frazier, and Sivrotka 2000). Simultaneously, the intellectual center of gravity within
psychiatry was shifting decisively away from psychoanalysis and a bio-social model of
mental disorder and towards a biologically reductionist view of mental illness. The social,
so far as most psychiatrists were concerned, went from being directly relevant to being at
best marginal to their research. Thus, political pressures to avoid controversial and
sensitive work on the sociological dimensions of mental disorder was reinforced by the
demands of psychiatry for an increased focus on neuroscience and psycho-
pharmacological research.

Scholars working on the sociology of mental illness thus now confront a very different
research environment than the one that prevailed a quarter century ago. The range of
intellectual and policy issues thrown up by the dramatic changes that have marked the
mental health sector in the same period mean, however, that there is an abundance of
challenging topics for the study of which sociological perspectives are indispensable. The
range and scope of this Encyclopedia is vivid testimony to the intellectual vitality of the
field, and will, one hopes, make a useful contribution to the next generation of sociological
research on the cultural sociology of mental illness.

*****
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