Abstract
Perhaps the biggest contrast between medical sociology and the sociology of mental health and illness is the relative dearth of books published by sociologists specializing in mental health versus those in medical sociology. I have served on the Medical Sociology Section Committee for the Eliot Freidson Award for best book published in medical sociology and enjoyed reading the half dozen or so books recently published and vying for that award. However, in the sociology of mental health there are only a half dozen or so books published in the past decade (since 2000) that would be contenders for a similar award. The sociology of mental health is a field that has been largely defined by important journal articles, and there have been several special issues of the Journal of Health and Social Behavior which have dealt primarily with findings from the field of mental health. In addition, the Mental Health Section has its own journal, Society and Mental Health. That said, there are still many notable books that need to be read and which will continue to shape the discipline for the foreseeable future. I am also happy that these books have continued the critical legacy of Erving Goffman in his 1961 book, Asylums.
A number of important books written by sociologists have challenged the dominance of biological models of mental illness and especially the hegemony of diagnostic psychiatry (where mental health problems are reduced to discrete diagnoses based upon the American Psychiatric Association’s Diagnostic and Statistical Manual). Allan Horwitz’s (2002) Creating Mental Illness began the frontal assault on diagnostic psychiatry and challenged the usefulness of diagnostic classification systems and the delineation of over 400 mental disorders based upon criteria set by the Diagnostic and Statistical Manual (DSM). The DSM is now in version IV, with version V being quite controversial and hence delayed until 2013 because of the ongoing debates about the continued expansion of clinical diagnoses and the fuzzy boundary between normal and pathological conditions (for example, the DSM-V originally contained criteria for determining “pre-pathological” states). Horwitz’s main point is that the DSM overstates the amount of mental disorder, viewing all evidence of psychiatric symptoms, regardless of their cause, as evidence of pathology. He admonishes both researchers and clinicians to distinguish between mental disorders and normal reactions to social stressors and/or deviance—laying the groundwork for a sociological understanding of mental disorder and mental health problems.
Creating Mental Illness is clearly argued, and provides readers with a concise and well-written account of the origins of dynamic psychiatry (Freud) and the shift to a medical model and clearly-defined disease entities in the 1970s with the development of the DSM-III. Diagnostic psychiatry is based upon biological understandings of the operation of the brain, and Horwitz provides a very readable overview and critique of the data used to provide support for the biological model. The reader is left with a clear understanding that biologically-derived explanations emphasize individual differences to the neglect of group, environmental, or population differences. He concludes that the dominant (and still current) view of mental disorders as brain diseases is a cultural belief, hence the title, which emphasizes the social construction of mental illness. Rather than biology, researchers need to focus on the social causes of distress and mental disorder: those life events that are negative and uncontrollable including poverty, instability, unemployment, and neighborhood disorganization. Creating Mental Illness is also notable in that it is the only non-edited book to have won the American Sociological Association Best Publication in Mental Health Award.
The critique of diagnostic psychiatry is continued in a book co-authored by Horwitz with Jerome Wakefield, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007). While Horwitz used depression as an example of how the DSM fails to distinguish normal responses to life’s problems from pathology, The Loss of Sadness uses this example to provide a thorough history and overview of the definition and classification of depression, taking us inside the DSM and the operation of its classification system. The overall point is that the DSM “does not recognize that many problems in living are not mental disorders” (p. 115). Furthermore, since the 1990s psychiatrists have argued that the symptom threshold for depression needs to be lowered, and that relatively mild symptoms of depression need to be seen as risk factors for more serious conditions (themes which recur in the continued debates over the revisions to the DSM). Horwitz and Wakefield provide evidence for the growing role of drug treatments and the advantages gained by the pharmaceutical industry with the medicalization of “ever-widening realms of human experience” (p. 217). They also criticize both anthropology and sociology for failing to distinguish normal sadness from clinical depression in their research, and the reliance on DSM classification systems as the basis for understanding the prevalence and treatment of mental health problems.
These sociological critiques of diagnostic psychiatry have been extended by two books published in 2010. While neither book is by a sociologist, they are important and should be read by sociologists. Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis is written by Daniel Carlat, a psychiatrist who uses his own clinical experiences and past ties to the pharmaceutical industry to illustrate the point that psychiatrists do little more than prescribe drugs for an ever-expanding series of mental health problems. Carlat is not an anti-psychiatrist; he believes that medications have a role, but he is critical of psychiatry for relying solely on drugs to the neglect of therapy: “We treat the neurotransmitters, and we refer the person to somebody else” (p. 16). His critique of the DSM is buttressed by descriptions of how he as a psychiatrist uses the DSM to arrive at a diagnosis, and describes cases where drugs were, and were not, effective. Carlat then takes the reader inside the workings of the pharmaceutical industry, providing insight into how psychiatrists are influenced by drug representatives and the money provided by pharmaceutical companies for research which has driven both the proliferation of clinical diagnoses and the use of drugs. Psychiatry is clearly under attack as Carlat provides detailed information on the financial gains of leading psychiatrists. He argues for a new model of psychiatry, where psychologists and nurse practitioners would be able to prescribe medications and psychiatrists would forego medical training for enhanced training in therapy. This book is very readable, and quite useful for classroom use. While Carlat relies upon his own clinical experience, he is also familiar with and uses the dominant sociological literature as a basis for his critique of psychiatry.
A more thorough and detailed critique of psychiatric medications and the medicalization of mental health problems can be found in Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America. In contrast to Carlat’s first-hand description, Whitaker’s book is based upon reviews of the psycho-pharmacologic research where he demonstrates repeatedly that despite the widespread use of psychiatric medication, recovery from mental disorders has actually declined and rates of disability have risen. Rather than curing mental illness, psychiatric drugs are fueling an epidemic of mental illness (p. 11). While he does not cite Horwitz’s Creating Mental Illness, Whitaker poses the question, “Do we have a paradigm of care that can, at times,
We all need to read Whitaker’s book; he provides a solid empirical basis for understanding the increasing prevalence of mental disorder as an iatrogenic illness. The history and key research on the major psychiatric drugs and their use in treating schizophrenia, bipolar disorder, anxiety, depression and ADHD is reviewed. The iatrogenic effects of the drugs are illustrated with data produced by the pharmaceutical industry and psychiatrists, where rather than fixing “chemical imbalances in the brain, the drugs create them” (p. 207). The story does not end here—Whitaker takes up the point raised by Horwitz in 2002, that belief in the medical model is a cultural belief. Whitaker goes well beyond Horwitz and shows us how and why the medical model was created and perpetrated by the American Psychiatric Association, The National Institute of Mental Health, and National Alliance on Mental Illness, and how it has been maintained by discrediting any criticisms of the medical model and withholding evidence as to the lack of clinical efficacy for the newer blockbuster drugs. As does Carlat, Whitaker gives us the sorry details of the profits racked up by the pharmaceutical industry and its key opinion leaders: the psychiatrists who conduct the drug trails and promote the drugs. With Carlat, he argues that we need to begin to think about drugs more scientifically, increasing our empirical understanding of when and how they work. We need to begin with the fact that we do not know what causes mental disorder, “We need to talk about what is truly known about the biology of mental disorders, about what the drugs actually do, and about how the drugs increase the risk that people will become chronically ill” (p. 359). While some may see Whitaker as too polemical, I was glad to be taken to a place where research begins from a critical stance—certainly where the sociology of mental health and illness started in 1961 with Goffman’s Asylums.
Medical sociology also has a history of books focusing on the medical profession, hence the Eliot Freidson Outstanding Publication Award. Sadly, such works are far less common in the sociology of mental health, with a few exceptions. First is T.M. Luhrmann’s Of Two Minds: The Growing Disorder in American Psychiatry (2000). Luhrmann is an anthropologist who conducted an ethnographic study of psychiatric residents in the 1990s. Her book details how the divide between psycho-pharmacology and psycho-dynamic therapy was created and is maintained. Luhrmann takes us inside the psychiatric training criticized by Daniel Carlat, showing how the two approaches to psychiatric treatment (for simplicity, medication versus therapy) work as distinct cultures. Psychiatric residents learn their roles via a three-year apprenticeship, where they move from memorizing criteria for diagnoses to recognizing prototypes. In this process “the inherent ambiguity of psychiatric diagnosis” (p. 45) disappears and “diagnoses begin to feel like real, distinct objects in the body” (p. 42). As with other medical specialties, psychiatrists train for uncertainty and learn detachment. However, psycho-therapy involves empathy and the formation of an intimate bond with the patient. Since this kind of communication is not learned in medical school or residency, psychoanalysis involves additional, costly training and continued willingness to engage in one’s own psychotherapy. Given the need for recognition as a medical expert within the larger medical field, psycho-pharmacology is more highly valued; it is seen as scientific, more “macho.”
While medical culture may itself reinforce the preference and dominance of medication therapy, Luhrmann describes the time in the 1980s when medication and psychotherapy co-existed relatively peacefully. What happened? Managed care and its emphasis on cost effective, clinically efficacious treatment became the dominant force in medicine and mental health. Managed care emphasizes short term, outcomes-oriented care, and reimbursement is tied to clinical diagnoses. In addition, Medicaid rules which allowed psychologists and social workers to bill for therapy undermined the authority of the psychoanalyst, while funding for research reinforced the professional status of the neuro-psychiatrist. “Psychopharmacology is the great, silent dominatrix of contemporary psychiatry. It is what psychiatrists do that other mental health professionals cannot do” (p. 47). Luhrmann concludes by arguing that medical solutions do not work for patients with chronic illnesses, and that a reliance on medications allows psychiatrists to deny their moral responsibility to provide comprehensive care.
My own book, Tie a Knot and Hang On: Providing Mental Health Care in a Turbulent Environment (2004), provides a more comprehensive examination of the effects of managed care on the work of mental health providers in both public and private practice. The book draws from organization sociology (primarily institutional theory) and examines how organizational contexts enable, govern, and constrain the interactions that mental health clinicians have with their patients. Managed care imposes an institutional logic of commodification, which is in conflict with the professionally-driven logics of community mental health care. Tie A Knot and Hang On also provides an analysis of the treatment ideologies of mental health providers and their emotional labor. Managed care not only contains bureaucratic demands for short term, efficacious therapy and medications, it also constrains the emotional labor of clinicians, leading to higher levels of psychological burnout. Mental health providers experience frustration and psychological burnout as they “must make difficult choices between their own professional beliefs about necessary care and organizationally mandated constraints on that care” (p. 11). My interviews with mental health care providers ended with my asking them, “Where do you think mental health care will be in 10 years?” The answers were overwhelmingly negative, and stand as a sharp contrast to interviews I conducted during the 1980s in the era of community-based care. There was consensus that managed care would further fragment the services needed by those with chronic mental illnesses, and that providers would continue to have to meet the needs of a growing patient population with fewer resources. Sadly, these predictions have been realized.
The last book to discuss focuses on mental health policy, and ties together nicely the various themes raised in the books described above. Gerald N. Grob and Howard H. Goldman in The Dilemma of Federal Mental Health Policy: Radical Reform or Incremental Change? (2006), provide a testament to the federal policy process’ predilection for incremental change. The authors describe the changes in federal mental health policy from World War II to the turn of the twenty-first century. During this time, there has been a continued shift of care from state institutions to the community, and a contradictory shift in fiscal responsibility for this care from local communities and states to the federal government. At the same time, as already described, the numbers of people with psychiatric diagnoses has rapidly expanded. However, the mental health system has become more fragmented and those with the greatest needs, individuals with severe mental disorders, have experienced deterioration in care.
The Dilemma of Federal Mental Health Policy is an excellent combination of historical overview and a political analysis of intergovernmental rivalries. Unlike other arenas of health policy, “what is striking is the absence of any consensus on the underlying causes responsible” for mental health disorders (pp. 1–2). Consequently there can be no consensus over solutions to the many problems raised by mental illness, especially severe and persistent mental illness. The authors briefly review mental health treatment prior to the 1900s in the prologue; giving a quick description of moral treatment and the emergence of the mental hygiene movement. Chapters One and Two describe deinstitutionalization and the emergence of community psychiatry, providing keen insight into the leadership provided by Robert H. Felix and other governmental insiders in beginning the shift to a stronger federal role via the National Institute of Mental Health (NIMH). However, deinstitutionalization never involved a planned policy shift, and the authors attribute this to the “decentralized character of the American political system” (p. 18). Chapters Three and Four focus on the Carter administration’s Presidential Commission on Mental Health (PCMH), providing much detail on the political maneuvers behind the ultimate passage of the Mental Health Systems Act in 1980. The 1970s were important to the mental health field as there was a shift away from mental illness to a focus on mental health, with a corresponding emphasis on the role of the environment, social services, and prevention. In today’s era of narrow focus on individual pathology, it is important to remember (or learn, depending on the reader’s age) that at one time poverty, racism, and the need for broad political reform were seen as critical to improved mental health. However, all of these competing interests undermined the ability of the PCMH to produce focused recommendations which would have any impact. Instead, the Mental Health Systems Act “created an extraordinarily complex process of combined local, state, and federal planning and management” (p. 109). Of course, the Mental Health Systems Act was rendered “moot” (p. 114) by Reagan’s Omnibus Budget Reconciliation Act of 1981, which not only reduced funding for mental health services, but reverted funding to the states via block grants.
What we have seen since the failure of the PCMH was a long period of incremental reforms, and a renewed emphasis on the needs of those with severe, persistent mental illnesses via the expansion of Medicare and Medicaid funding for this population. The 1990s encompassed not only the domination of managed care, but the first ever report by the Surgeon General on Mental Health in 1999; followed by a 2001 report (Mental Health: Culture, Race, and Ethnicity) which was developed in response to criticism of the Surgeon General’s report. Services integration and improved patient outcomes became the focus of NIMH funding. However, fragmentation remained a key problem, highlighted in the 2003 President’s New Freedom Commission on Mental Health which was a result of collaboration between the key agencies involved in mental health care (the NIMH, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation, and the Mental Health America). Several other reports have emerged, including a 2005 federal action report, which highlights key concerns and problems, but there have been no specific recommendations nor funding for improvements in mental health services.
The Dilemma of Federal Mental Health Policy takes us to the present, and leaves us with little hope for mental health reform, or improved systems of care for those with serious mental health problems. With the decline of public sector mental health programs, those with a serious mental illness find themselves in jails or prisons. As described by David Mechanic in The Truth About Health Care: Why Reform is Not Working in America (2006), the criminalization of the mentally ill “represents the greatest scandal of our health care system, and a situation which should embarrass all thoughtful citizens” (p. 80). I agree, and would point readers to Pete Early’s Crazy: A Father’s Search Through America’s Mental Health Madness (2006) for a first-hand account by a journalist of how the mental health treatment system operates. It is not only embarrassing; I would go so far as to argue it is immoral. At the same time, the pharmaceutical industry and diagnostic psychiatry are increasing the scope of individual pathology and broadening the ranks of the worried well who seek medical solutions to the many pressures of modern society. Norah Vincent’s Voluntary Madness: Lost and Found in the Loony Bin (2008) is another journalistic account of the author’s immersion in the patient role. Vincent has suffered from depression (which she comes to view as the malaise of our age rather than an illness), and describes her experience as a voluntary patient in three different inpatient settings: a public, big city hospital; a smaller, Catholic institution in the Midwest; and an alternative hospital with a focus on intensive psycho-therapy. Following Goffman’s analysis of total institutions, there is insight into the changing nature of social control and staff/ patient relations in each of these institutional settings, with a good analysis of the sources of both staff and patient empowerment and autonomy (or its lack). Vincent offers a good account of her growing critique of the medical model of depression and her realization that she is one of the “overdiagnosed” (p. 88), lending a nice first hand account of the problems with diagnostic psychiatry.
So where does this leave sociologists? I think we need a renewed emphasis on systems of care (or lack thereof) and more attention to how patients experience this care (or lack thereof). We need more research on how changes in the organization and financing of mental care have impacted the quality of patient’s lives; data which can then be used to effect some policy changes. I can point to one work by a junior scholar, which certainly fills some of these gaps and may open the door to more notable books in the sociology of mental health. Kerry Dobransky was the winner of the 2010 ASA Award for Best Dissertation in Mental Health which will be published by Rutgers University Press in 2013. In Managing Madness in the Community: The Challenge of Contemporary Mental Health Care, she examines two community-based mental health care systems and the experiences of patients in these institutions. The analytical lens is organizational theory, and Dobransky describes how conflicting institutional logics result in fragmented care. Not only is there insight into patient experiences, but into the conflict faced by mental health care providers and community mental health organizations who must provide both medical and social services.
Finally, there are numerous edited volumes in the sociology of mental health, and readers should certainly seek these out. Several handbooks provide concise summaries of the extant knowledge base in the sociology of mental health, and others emphasize research in one of the most important arenas for research: stress and social support. One edited volume that should have appeal to not only mental health scholars, but the larger audience of sociologists is Mental Health: Social Mirror, edited by William R. Avison, Jane D. McLeod and Bernice A. Pescosolido (2007). Social Mirror seeks to bring the sociology of mental health to the center of sociological inquiry, describing the contributions that mental health research has made to major substantive areas in sociology (social stratification, the sociology of work, race and ethnicity, life course and social psychology, organizational sociology) as well as the importance of key concepts (such as social integration and stigma) in the sociology of mental health to sociological research. This volume is certainly essential reading because it encourages us to think outside the box and to look beyond the confines of our academic specializations to see how the sociology of mental health is not only informed by, but has informed, sociological analysis more generally.