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A Sociology of Mental Health and Illness Rogers and Pilgrim A SOCIOLOGY OF MENTAL HEALTH AND ILLNESS Third Edition • How have sociologists theorized and researched mental health and illness? • In what ways do sociologists approach this topic differently to those from other disciplines? • How do we understand mental health problems in their social context? This bestselling book provides a clear overview of the major aspects of the sociology of mental health and illness, and helps students to develop a critical approach to the subject. In this new edition, the authors update each of the chapters, taking into consideration recent relevant literature from social science and social psychiatry. A new chapter has been included on the impact of stigma, which covers an analysis of the responses of the lay public to mental health and illness and representations of mental health (particularly in the media) in a post-institutional context. A Sociology of Mental Health and Illness is a key teaching and learning resource for undergraduates and postgraduates studying a range of medical sociology and health-related courses, as well as trainee mental health workers in the fields of social work, nursing, clinical psychology and psychiatry. Anne Rogers is Professor of the Sociology of Health Care and currently directs a programme of research on self-management and chronic disease management at the National Primary Care Research and Development Centre, Division of Primary Care, University of Manchester. Her PhD on psychiatric referrals from the police began her academic career. Her current research interests include sociological aspects of primary care and mental health. David Pilgrim is Clinical Dean, Teaching Primary Care Trust for East Lancashire and Honorary Professor at the Universities of Liverpool and Central Lancashire. His career has been divided between higher education and the NHS. He trained as a clinical psychologist before completing his PhD on NHS psychotherapy. He subsequently completed a Masters degree in Sociology. Since then he has retained both a clinical and research interest in many aspects of mental health work.

Cover illustration: The Cure of Madness by Hieronymus Bosch (Prado, Madrid)

Cover design: Barker/Hilsdon

 

 

A SOCIOLOGY OF

Mental Health and

Illness

ANNE ROGERS AND DAVID PILGRIM

THIRD EDITION

Socio-mental health pb 1/6/05 10:07 am Page 1

A sociology of

mental health and illness

Third edition

A sociology of

mental health and illness

Third edition

Anne Rogers

and

David Pilgrim

Open University Press

Open University Press

McGraw-Hill Education

McGraw-Hill House

Shoppenhangers Road

Maidenhead

Berkshire

England

SL6 2QL

email: [email protected]

world wide web: www.openup.co.uk

and Two Penn Plaza, New York, NY 10121-2289, USA

First published 2005

Copyright © Anne Rogers and David Pilgrim 2005

All rights reserved. Except for the quotation of short passages for the purposes of

criticism and review, no part of this publication may be reproduced, stored in a retrieval

system, or transmitted, in any form, or by any means, electronic, mechanical,

photocopying, recording or otherwise, without the prior written permission of the

publisher or a licence from the Copyright Licensing Agency Limited. Details of such

licences (for reprographic reproduction) may be obtained from the Copyright Licensing

Agency Ltd of 90 Tottenham Court Road, London, W1T 4LP.

A catalogue record of this book is available from the British Library

ISBN-13: 978 0335 21583 6 (pb) 978 0335 21584 3 (hb)

ISBN-10: 0335 21583 1 (pb) 0335 21584 X (hb)

Library of Congress Cataloging-in-Publication Data

CIP data applied for

Typeset by RefineCatch Ltd, Bungay, Suffolk

Printed in the UK by Bell & Bain Ltd, Glasgow

For Steven and Jack (Again!)

Contents

Preface to the third edition xiii

Acknowledgements xix

1 Perspectives on mental health and illness 1

Chapter overview 1

The perspectives outwith sociology 2

Psychiatry 2

Psychoanalysis 4

Psychology 5

The statistical notion 5

The ideal notion 6

The presence of specific behaviours 7

Distorted cognitions 7

The legal framework 8

Conclusion about the perspectives outwith sociology 10

The perspectives within sociology 11

Social causation 12

Critical theory 12

Social constructivism 15

Social realism 16

Discussion 18

Questions 22

For discussion 22

Further reading 22

2 Stigma revisited and lay representations of mental health problems 23

Chapter overview 23

Lay views of psychological differences 24

Stereotyping and stigma 26

Intelligibility 28

Competence and credibility 30

Does labelling matter? 33

The role of the mass media 35

Social exclusion and discrimination 37

Social capital, social disability and social exclusion 39

Conclusion 40

Questions 42

For discussion 42

Further reading 42

3 Social class and mental health 43

Chapter overview 43

The general relationship between social class and health status 44

The relationship between social class and diagnosed mental illness 47

Social class, social capital and neighbourhood 50

The relationship between poverty and mental health status 52

Labour market disadvantage and mental health 54

Housing and mental health 54

Social class and mental health professionalism 55

Lay views about mental health and social class 57

Discussion 58

Questions 61

For discussion 61

Further reading 61

4 Women and men 62

Chapter overview 62

The over-representation of women in psychiatric diagnosis 63

Does society cause excessive female mental illness? 64

Vulnerability factors 65

Provoking agents 65

Symptom-formation factors 65

Is female over-representation a measurement artefact? 66

Sex differences in help-seeking behaviour 67

Are women labelled as mentally ill more often than men? 69

viii A sociology of mental health and illness

The effects of labelling secondary deviance – women and minor

tranquillizers 72

Men, dangerousness and mental health services 74

Gender and sexuality 76

Discussion 78

Questions 79

For discussion 80

Further reading 80

5 Race and ethnicity 81

Chapter overview 81

Theoretical presuppositions about race 82

Race and health 83

The epidemiology of mental health, race and ethnicity 84

Methodological cautions about findings 87

Type of service contact 87

Disproportionate coercion 90

Black people’s conduct and attributions of madness – some

summary points 91

Asian women and the somatization thesis 94

Irish people and psychiatry 96

Discussion 98

Questions 100

For discussion 101

Further reading 101

6 Age and ageing 102

Chapter overview 102

Emotions and primary socialization 103

Sociology, childhood and mental health 105

Childhood sexual abuse and mental health problems 106

Social competence in adulthood 110

Dementia and depression in older people 113

Discussion 116

Questions 118

For discussion 118

Further reading 118

Contents ix

7 The mental health professions 120

Chapter overview 120

Theoretical frameworks in the sociology of the professions 121

The neo-Durkheimian framework 121

The neo-Weberian framework 122

Social closure 122

Professional dominance 122

The neo-Marxian framework 123

Eclecticism and post-structuralism 124

Mental health professionals and other social actors 125

Sociology and the mental health professions 127

Eclecticism and post-structuralism 128

The neo-Weberian approach 132

Symbolic interactionism 133

The influence of the sociology of deviance 134

The influence of the sociology of knowledge 134

The influence of feminist sociology 135

The impact of legislative arrangements and service redesign 135

Discussion 137

Questions 138

For discussion 139

Further reading 139

8 The treatment of people with mental health problems 140

Chapter overview 140

Therapeutics 141

A brief social history of psychiatric treatment 141

Criticisms of psychiatric treatment 143

Why have physical treatments tended to predominate? 143

Minor tranquillizers 145

Major tranquillizers 146

Antidepressants 149

Psychological therapies 150

Why is there a problem of legitimacy about the effectiveness of

psychiatric treatment? 151

The moral sense of ‘treatment’ 152

Who is psychiatry’s client? 153

The question of informed choice 153

Insight 154

The morality of others 155

Comprehensive and comprehensible information 156

Coercion 156

Specifiable actions 156

The social distribution of treatment 157

x A sociology of mental health and illness

The impact of evidence-based practice on treatment 158

Disputed evidence about ECT 159

Users’ views as evidence in service research 159

Tackling social exclusion as a focus of treatment 160

Governmentality and self-help 162

Discussion 163

Questions 165

For discussion 166

Further reading 166

9 The organization of mental health work 167

Chapter overview 167

The sociology of the hospital 168

The rise of the asylum 169

The crisis of the asylum 172

Responses to the crisis 175

The ‘pharmacological revolution’ 176

Economic determinism 178

Changes in the organization of medicine: a shift to acute problems

and primary care 179

Community care and reinstitutionalization 180

Public health, primary care and the new technology revolution 185

Discussion 187

Questions 189

For discussion 189

Further reading 190

10 Psychiatry and legal control 191

Chapter overview 191

Legal versus medical control of madness 192

Mentally disordered offenders 193

The problematic status of personality disorder 194

The persistence of a problematic concept: the case of ‘dangerous and

severe personality disorder’ 198

Socio-legal aspects of compulsion 199

The globalization of compulsion 201

Professional interests and legislation 203

Dangerousness 204

Violence and mental disorder 204

Suicide and mental disorder 208

Impact on patients of their risky image 209

Discussion 210

Contents xi

Questions 211

For discussion 212

Further reading 212

11 Users of mental health services 213

Chapter overview 213

The diffuse concept of service use 214

Relatives or ‘significant others’ 214

Users as patients 217

The disregarding by researchers of those users’ views that do not

coincide with the views of mental health professionals 218

The notion that psychiatric patients are continually irrational and so

incapable of giving a valid view 218

Patients and relatives are assumed to share the same perspective, and

where they do not, the views of the former are disregarded by

researchers 219

Framing patient views in terms which suit professionals 219

Users as consumers 220

Literature on psychiatric patient satisfaction and dissatisfaction 224

Users as survivors 225

The phenomenology of surviving the psychiatric system 225

Survivors as a type of new social movement 226

Users as providers 229

The tension between advising, providing and campaigning 231

Discussion 232

Questions 233

For discussion 234

Further reading 234

References 235

Index 265

xii A sociology of mental health and illness

Preface to the third edition

Our first preface in 1993 emphasized that this book was A, not, The Sociology of

Mental Health and Illness. Today, more than ever, it is quite a risk to write ‘The

Sociology’ of anything. Moreover, as the wide-ranging references listed at the

end of the book indicate, we continue to draw our material from sociology but

also many other sources, including psychology and psychiatry. Sociological

analyses of our topic are not offered only by sociologists. Since the previous

edition was published in 1999, good examples of this point from other discip￾lines have appeared, including Richard Bentall’s Madness Explained (2003) and

Christopher Dowrick’s Beyond Depression (2004) (from psychology and medi￾cine respectively). Both of these provide illuminating ways of exploring psy￾chological abnormality in its social context by emphasizing historical analysis

and a close attention to the meaning of the personal accounts of people with

mental health problems.

Our development of sociological reasoning is helped by the examination

and incorporation of work in these other disciplines. Sometimes this involves

using the empirical findings of their studies to build up an argument. Some￾times it is about applying a sociological approach to their production. A fur￾ther complication is that some sociologists now co-author their work with

collaborators from other disciplines and this joint work may appear in non￾sociology journals. Although disciplinary silos are still often jealously pro￾tected in the academy, research in an applied and broad area like mental

health invariably leads to a range of inter-disciplinary outcomes.

As a consequence of these considerations, we cannot write a sociology book

which only refers to sociology titles (or if we did the product would be much

the poorer). However, this broad engagement with our topic means that

boundary lines have to be drawn at times. For example, our partial and parti￾san summary of the field means that we focus on some native concerns in

detail. This is exemplified in the chapter on race in which we overwhelmingly

dwell on the post-colonial British picture, although in many other chapters

the material would be relevant to any Anglophone audience.

We wrote the first edition of the book at the end of the 1980s when socio￾logical debates about mental health and psychiatry were not as salient as they

had been during the 1960s and 1970s. During those earlier decades, mental

illness had been subject to considerable scrutiny and was used as an exemplar

in mainstream sociological theorizing on deviance and social control. The

popularity of sociological work about psychiatry during that ‘counter-cultural’

period was also fuelled by radical critiques from some mental health profes￾sionals, who questioned their own traditional theory and practice. While a

sociological interest in mental health continued in North America, in Britain

the 1980s witnessed sociological interest in health and illness turning more

and more to mainstream topics of physical and chronic illness. Sociology’s

reputation for being an intellectual fellow traveller of, or contributor to, ‘anti￾psychiatry’ had diminished. (Note: sociology was a fellow traveller but the

main drivers of ‘anti-psychiatry’ were psychiatrists.)

The sociological imagination of anti-psychiatric writers was challenged.

First there was the appearance of Anthony Clare’s urbane and reformist

Psychiatry in Dissent (1976), which defused the libertarian and Marxian

resonances of psychiatry’s critics and then by a more aggressive return to

psychiatric tradition in John Wing’s Reasoning About Madness (1978). This

contained a contemptuous attack upon the ideas of Michel Foucault. Wing’s

defence of his profession involved a dismissal of lay views of madness and an

appeal for more robust medical conceptualizations of mental disorder. This

sort of critique from those like Wing, who until then had worked collabora￾tively with sociologists, helped to deflate sociological confidence in the study

of mental health and illness. Goodwill between sociology and psychiatry was

also lost in these cross-disciplinary spats. The legacy of this loss is still evi￾dent today, with psychiatric texts expressing doubts about the worth of

sociological contributions to an understanding of mental health (Gelder et al.

2001).

By the late 1990s, when our second edition appeared, several contradictions

seemed to have emerged in: mental health service practices; civil society’s

interest in mental health; and the analyses sociologists deploy in understand￾ing these social relationships. During the mid-1990s the topics of mental

health and illness enjoyed some rekindled sociological attention. Consumer￾ism and user participation within the NHS and wider society found a

particularly strong voice within mental health campaigns.

Sociological work on the problematic history of institutionalization and

deinstitutionalization and women’s mental health were re-invigorated by a

series of government social policy considerations, as well as by the rise of

feminist ideas within community care debates. At the same time, within

psychiatry, biological ideas had found a fresh vigour, with a renewed interest

and enthusiasm for psychopharmacology, hi-tech brain photography and

behavioural genetics.

Reflecting on the ‘decade of the brain’, an academic champion of biological

psychiatry, Samuel Guze (1989) had asked the rhetorical question, ‘biological

psychiatry: is there any other kind?’. If this sort of triumphalist conclusion had

been genuinely warranted by evidence, then, it would seem, decades of

socially informed correctives to bio-reductionism had all been in vain. After its

professional dismissal as a therapeutic abomination, psychosurgery, which

involves the destruction of healthy brain tissue, returned to respectability

within NHS medical practice. Despite recurrent hostile user campaigns ECT

remained the ‘treatment of choice’ for severe and intractable depression. These

xiv A sociology of mental health and illness