Sociology And Psychiatry Research Paper

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Sociology and psychiatry have a longstanding relationship which has never been free of tensions and can at least be characterized as ambivalent. On the one hand, psychiatry as a subspecialty of medicine, which has to solve concrete problems in everyday life, has become a subject matter of sociology, which often criticizes psychiatry’s concepts and practices. On the other hand, psychiatry has profited from cooperating with sociologists by making use of sociological research methods. This research paper sets out with describing the relationship between the two disciplines, and then proceeds to discussing the contributions made by sociology towards the understanding of how psychiatry functions (‘sociology of psychiatry’) before describing the uses of sociology within the field of psychiatry (‘sociology in psychiatry’).

1. Sociology And Psychiatry—An Uneasy Relationship

Sociology and psychiatry have a common topic: deviant behavior. Sociology, as a scientific discipline which examines the rules by which society functions, must have a genuine interest in phenomena which threaten these rules. Emile Durkheim (1895), one of the founding fathers of sociology, points out in his famous book, The Rules of the Sociological Method, that the standards and rules defining what is pathological help to reinforce the norms and values of society. For psychiatry, in turn, a specific form of deviant behavior, called mental illness, is its very ‘raison d’etre.’ In this respect, the relationship between sociology and psychiatry could be regarded as a relationship of equal partners joining their intellectual forces in analyzing a topic of common interest, though using different approaches. However, there is also a different type of relationship between these two disciplines, in so far as one of them, psychiatry as a subspecialty of medicine, has become the subject matter of the other, sociology.

When discussing the relationship between sociology and psychiatry, a profound difference between these two disciplines has to be kept in mind: Psychiatry is not only a scientific discipline—like sociology—but also a practice field, akin to medicine in general, or to education. Sociologists might aim at changing things, but sociology has never been a major player in practical problem-solving, in contrast to psychiatry, which from its very beginning 200 years ago was assigned the societal task of treating the mentally ill or managing (controlling, as sociologists would say) the problem of mental disorders. Van der Geest (1995), in comparing medicine and social sciences (exemplified by cultural anthropology), speaks of two ‘ethnocentrisms,’ i.e., two different cultures, which are dissimilar in three aspects. The culture of medicine is practical and problem-oriented (doctors are supposed to find concrete solutions to concrete problems), whereas the social sciences culture is theoretical; doctors have no time to lose (they have to act promptly before it is ‘too late’), social scientists are not in a hurry to finish their work; finally, doctors measure their success in maintaining and restoring people’s health (they are accountable to people); for social scientists the fulfilment of their task does not lie in an improvement of the lives of the people studied, but in the production of texts about them. The ‘ethnocentrism’ of these two disciplines makes communication difficult and prone to misunderstandings.

Psychiatry’s relationship to sociology is ambivalent. On the one hand the application of sociological research methods to psychiatric problems have undoubtedly contributed to raise psychiatry’s societal visibility and importance—by furthering epidemiological research, which has shown that between one quarter and up to nearly half of the US population suffer from at least one diagnosable mental disorder during a person’s life time (e.g., Robins and Regier 1991, Kessler et al. 1994). On the other hand, sociologists have been, and still are, among the most radical critics of psychiatry, concerning both its concepts and its practice.

One further aspect renders the discussion of the relationship between sociology and psychiatry difficult: Both disciplines are extremely diverse within themselves. Sociology comprises a multitude of different philosophies (e.g., the ‘social constructivist’ and the ‘social realist’ perspectives) and research methods (e.g., the ‘quantitative’ and the ‘qualitative’ approaches). Psychiatry, both as a scientific discipline and a practice of identifying, explaining, and treating behavioral problems, which are deemed to be mental disorders, is even more heterogeneous, since psychological and sociological, as well as biological, approaches live under its roof. There is also a substantial overlap between each of the two disciplines and other fields. Sociology can be broadened to mean social sciences in general, and incorporate social anthropology, social psychology, and other disciplines. Furthermore, fields such as epidemiology, public health, social medicine, health economics, and others, if applied to psychiatric problems, would have to come in. Also, no attempt can be made here to discuss the boundaries of psychotherapy, clinical psychology, and social psychiatry in relation to clinical psychiatry.

For the purpose of this review, which addresses a broad audience, the author—who is a psychiatrist with strong interests in sociology—has found the dichotomy of the relationship between sociology and medicine, proposed by Robert Straus (1957), useful. Following Straus’ distinction between ‘sociology of medicine’ and ‘sociology in medicine,’ the ensuing part of the text will be divided into the ‘sociology of psychiatry’ and the ‘sociology in psychiatry.’ The first approach discusses sociological contributions toward the understanding of psychiatry as a whole, i.e., of how psychiatry behaves in terms of developing and using concepts and applying them in practice. The second approach deals with the application of sociological methods within the field of psychiatry. While these two approaches are sometimes intertwined, their separation is nevertheless useful for the purpose of orientation. This distinction can, at least implicitly, also be found in two recent reviews of the sociology of mental health and illness, to which the reader of the present review is referred for more detailed discussions of the issues raised here (Pilgrim and Rogers 1999, Busfield 2000). It has to be noted, though, that ‘sociology of mental health and mental illness’ is a broader concept than the two sociologies (of and in psychiatry) discussed here. In the following two sections these two approaches are illustrated by examples.

2. Sociology Of Psychiatry

The sociology of deviant behavior is central to sociology. Analyzing how boundaries are drawn between the normal and the abnormal, in other words, how the normal and the abnormal are classified, and analyzing how society reacts to the abnormal is one of the main interests of sociology. Since psychiatry has obtained an important definitional power over the specific type of deviant behavior called mental illness, and since it also has substantial influence on how such behavior is dealt with, it is obvious that psychiatry itself has become a subject matter of sociology. Sociologists have dealt both with psychiatric concepts and with the practice of psychiatry, with a special emphasis on the professional nature of psychiatry, on psychiatric services and the issue of legal vs. medical control of mental disorders.

2.1 Psychiatric Concepts

Sociologists have always expressed doubts about the coherence, credibility, and validity of psychiatric concepts and knowledge. The most profound sociological criticism of psychiatry concerns the concept of mental illness and its classification into discrete diagnostic entities. While such criticism has come forward from many quarters, including the antipsychiatric and consumer movements as well as scientific psychiatry itself (where some advocates favor dimensional rather than categorical concepts), the specific and original contribution from sociology was the labeling theory in the 1960s (Scheff 1999), a variant of what is called ‘social constructivism,’ i.e., a theory assuming that reality is a product of human definitions and not something waiting out there to be discovered (Brown 1995). More specifically, using ‘symbolic interactionism’ as their framework (a theory about how people map out social reality in everyday life), the advocates of ‘labeling theory’ claimed that the same deviant behavior may either go unnoticed or be labeled as mental illness, depending on the circumstances in which it occurs and is perceived by others. For instance, in a now famous study, Rosenhan (1973) observed that healthy test persons (‘Pseudopatients’) who presented themselves to psychiatric hospitals and told the doctor that they were hearing voices (saying ‘empty,’ ‘hollow,’ and ‘thud’) were admitted and received a psychiatric diagnosis. Once labeled, so the theory goes, the person’s identity and social status is altered significantly. Part of the process is that the labeled person internalizes the new identity ascribed to them and becomes trapped in the new role of a mental patient.

A radical social constructivist perspective creates hostility among doctors, patients, and relatives, since they get the feeling that it denies the reality of suffering connected with mental disorders. While the idea that mental disorders, especially schizophrenia, are caused by labeling is more or less abandoned in recent thinking, labeling is certainly a powerful mechanism when it comes to discussing the role of stigmatization and discrimination (Link et al. 1987). A more moderate form of criticizing psychiatric diagnosis is the notion that through the diagnostic process illnesses are ‘socially framed’ (Rosenberg 1992). Mirowsky and Ross (1989), while acknowledging that psychological problems are real, criticize that psychiatric diagnosis treats attributes as entities, and that psychiatrists often speak of psychological problems ‘as if they are discrete entities, entering the bodies and soul of helpless victims.’ They target especially the operationalization of psychiatric diagnosis in modern diagnostic systems, such as the Diagnostic and Statistical Manual III (DSM-III) (and onwards) of the American Psychiatric Association (1994). It has to be acknowledged, though, that the construction of DSM-III was partly a reaction to the criticism that psychiatrists were not able to diagnose mental disorders reliably (Rosenhan 1973). However, while operationalization might have increased the reliability of psychiatric diagnosis, the question of validity is still debatable. Brown (1995) has suggested that instances of medicalization of normal life problems (such as ‘late luteal phase dysphoric disorder—LLPDD’; now called ‘pre-menstrual dysphoric disorder—PMDD’) are mainly a feature of professional ‘expansionism.’

2.2 Psychiatry As A Profession

Sociologists have not only dealt with psychiatric concepts but also with the process of professionalization of psychiatry, which is linked closely to both conceptual issues and to the practice of psychiatry. The rise of the psychiatric profession during the nineteenth century has been regarded alternatively as having been due to its functional value for economic order and efficiency under capitalism (Scull 1979), and to its role for maintaining the moral, rather than the economic order (Foucault 1965).

Psychiatrists certainly have difficulties in agreeing with these views, since they have always seen themselves as primarily a helping profession, whose practice is based on scientific advances. There is a different strain of sociological analysis of psychiatry as a profession, going back to the German sociologist Max Weber, who postulated that professionals want to advance their own social status, persuade clients and potential clients about the need for the service they offer, corner the market in that service, and exclude competitors (Freidson 1970, Pilgrim and Rogers 1999). Other sociological approaches to the issue of professionalization include the sociology of deviance (crises in personal lives are reframed as mental illness), symbolic interactionism (regarding the professional power in negotiating the meaning of mental illness), and feminist sociology (men occupy higher-status positions within the more powerful professions).

The concept of power is central to this analysis, and the specific knowledge base of a profession (which can only be obtained by a difficult process of socialization) gives the profession power over its clients, its recruits and related occupational groups. With the emergence of nonpsychiatric mental health professionals, professional power has become a complex issue, since clinical psychologists, community psychiatric nurses, psychotherapists, to name only a few, are also increasingly professionalized and state registered. Also, in the era of managed care, professional autonomy and decision-making power are threatened increasingly by third-party authorization mechanisms.

Finally, those receiving care from professionals start to threaten traditional professional identities. They are themselves becoming more powerful in forming self-help and advocacy groups, and tend to use terms such as ‘clients,’ ‘consumers,’ and even ‘survivors of psychiatry,’ instead of the term ‘patients.’ These terms have different implications of how the traditional doctor–patient relationship is redefined. ‘Client,’ unlike ‘patient,’ implies partnership rather than submissivity and passivity. The term ‘consumer’ goes even further in claiming that patients have certain entitlements for service for which they can sue, and the concept of ‘survivor of psychiatry’ denies the right of psychiatry to intervene in a person’s problems. Pilgrim and Rogers (1999) give a detailed account of sociological thinking about these issues, and how the situation has changed since Talcott Parsons (1951) formulated the paradigm of the ‘sick role.’ According to Parsons, the sick role allows people to be exempted temporarily from social responsibilities, but, in exchange, they must accept that they cannot get well on their own, and that they have to look for professional help. Foucault’s (1977) concept of ‘productive power’ provides an interesting sociological framework for the evolving discourse between professionals and the (potential, actual, or ex-) users of their services.

2.3 Psychiatric Practice

The old mental hospital was the mainstay of psychiatry for over 150 years. At the end of this period, in the 1950s, the mental hospital (or the ‘asylum’ as it had been called) became a favorite topic of sociology. There were at least two reasons for this interest. Mental hospitals could be regarded as a ‘small society,’ an experimental situation, so to speak, in order to study sociological phenomena in general (Caudill 1958), and, probably more important, sociologists became critics of the impersonal way in which patients were treated. Goffman (1961), in his famous study based on participant observation, coined the concept of the ‘tal institution’ for the mental hospital and similar organizations which disregard the personal needs of their inmates. In a more rigid research design, Wing and Brown (1961, 1970) showed a strong association between the typical poverty of the social environment of the mental hospital and the ‘clinical poverty’ of psychopathological phenomena such as blunted affect and social withdrawal—a view which has been challenged later (Curson et al. 1992). In a different approach, social historians attributed the growth of the asylum during the nineteenth century to more general developments in society, such as the growth of humanitarianism (Jones 1960), of capitalism (Scull 1979), and of surveillance tendencies (Foucault 1977).

Beginning during the 1950s, in countries with large numbers of beds in psychiatric hospitals—such as the USA and the UK—the numbers of psychiatric beds, which had been steadily rising over the first half of the twentieth century, started to fall. While, for instance, in the USA, in the mid-1950s about 600,000 patients were in mental hospitals, this number had come down to below 100,000 some 50 years later. The debate about the reason for this fall is still not resolved.

Psychiatrists attribute it mainly to the introduction of the neuroleptic drugs (which can control delusions and hallucinations). Sociologists have suggested different explanations: That, with the growth of the welfare state, controlling by segregation had become too costly, and that the public’s attitude toward psychiatric patients had changed in the sense of becoming more favorable (for an overview, see Busfield 1986). Furthermore, differences in the extent and kind of implementation of community psychiatry in different countries have been related to different health and social welfare systems (Goodwin 1997).

Forster (2000) examined three sociological theories (political-economy: cost containment; professional dominance: psychiatric ‘expansionism’; and poststructuralism: maintaining order and control) about the process of de-institutionalization, and concludes that none of them explains sufficiently the move away from hospital to community psychiatry. He proposes that the kind and degree of the medicalization of psychiatry has changed profoundly: While mainstream psychiatry is now more medicalized than before, the treatment of less serious mental health problems cannot be monopolized any more by medicine, and is becoming increasingly the practice field of other professions.

Compulsory admission and compulsory treatment are an intrinsic part of psychiatric services. Since the beginning of the twentieth century the legal professions have been involved increasingly in the process of admissions to mental institutions in order to counteract what has been regarded as mismanagement by the medical professions. This has prompted sociologists to analyze the social processes involved. There are basically two sociological positions: Those seeing the legal and the medical systems as two competing institutions (Mechanic 1978), and those who argue that, in practice, they join to become one actor, a ‘treatment-control’ system which ‘takes care’ of residual cases viewed as problematic for society, although the written law distinguishes between treatment and control (Dallaire et al. 2000). In the UK and other countries, a new dimension has been added to this issue with the concept of a ‘community treatment order,’ which would allow compulsory medication for patients living in the community and would let the pendulum swing back to medical control (Pilgrim and Rogers 1999).

Finally, sociologists have also analyzed and criticized specific therapeutic approaches. An example is the classical antipsychotic drugs and the barriers to the professional recognition of their side effects, especially of tardive dyskinesia, as an ‘iatrogenic disease’ (Brown and Funk 1986).

3. Sociology In Psychiatry

Sociologists working within the field of psychiatry are often criticized by their colleagues that they accept psychiatric concepts naively. Robert Straus (1957) has noted that ‘the sociologist in medicine risks a good relationship, if he tries to study his colleagues.’ Work presented in this section is therefore clearly separated in nature from that discussed in the previous section. In principle, psychiatric diagnosis is taken for granted, or at least not regarded as problematical by these authors.

Typical variables investigated in psychiatric studies using sociological methods include gender, age, social class, and inequality, as well as ethnicity and race (Pilgrim and Rogers 1999). An overlap with the sociology of psychiatry can sometimes not be avoided, especially if questions of disadvantage, stigma, and mental health policy are the topic of a study. Gender is a typical example of such a topic belonging to both sociologies (Busfield 1996).

Sociologists in psychiatry have been, and are, active in a large number of fields. They study, or help to study, the distribution of mental disorders in society, and the social factors and processes which may be causal for mental illness or influence its course. They investigate which social factors prevent the early detection, and thus the early treatment, of mental disorders, and which factors influence ‘illness behavior’ or ‘help-seeking behavior’ (here conceptual issues such as the professional and lay definition of illness, i.e., aspects of the sociology of psychiatry, are involved), and how effective psychiatric treatments are under different institutional and social conditions. They have introduced new outcome measures for psychiatric interventions, which are less ‘illnesscentered’ and more ‘life-centered’ (such as quality of life, social functioning, disability, social support, burden on the family) and have promoted the use of these measures to assess the ‘reality of life’ of persons with mental disorders, including the effects of stigma. Finally, in times of increasing restrictions of funds for health services, sociologists apply these concepts to health policy and health economics.

It must be noted though that the epidemiological survey methodology cannot only be used to study the influence of social factors, but also of biological and genetic factors. In fact, before the advent of the molecular biological approach, but also still at the time of writing, many conclusions drawn by psychiatric geneticists were based on epidemiological studies on the distribution of specific mental disorders among the relatives of mentally ill persons.

A few important historical examples of ‘sociology in psychiatry’ are worth mentioning. During the 1930s, the Chicago school of urban sociology studied the distribution of psychiatric disorders, such as schizophrenia, across the city alongside other forms of deviant behavior, and found higher rates in deprived areas (Faris and Dunham 1939). In the 1950s and 1960s, groups of sociologists and psychiatrists carried out a number of seminal studies: Cumming and Cumming (1957) investigated public attitudes toward mental illness and tested the efficacy of a large intervention program (which turned out not to be successful), Hollingshead and Redlich (1958), and Langner and Michael (1963) found an association between lower social class and mental illness. Srole et al. (1962) demonstrated the astonishingly high prevalence of mental disorders in metropolitan New York. Star (1955) found that public attitudes towards the mentally ill were stereotyped and quite unfavorable. Finally, Brenner (1973), in a time series analysis covering 117 years, demonstrated that in times of economic recession the yearly rates of admissions to mental hospitals in New York increased.

A few more recent studies and topics applying sociological research methods are described here by way of illustration. Brown and Harris (1978) conducted a detailed sociological analysis on the etiology of depression in women and found that, among women who experienced a major life event, only those who had no close confidant, or in whom other social vulnerability factors were present, became depressed. Concerning the presumed dangerousness of psychiatric patients, Steadman et al. (1998) reported that psychiatric patients who did not abuse drugs or alcohol had the same rates of violence as their nonpatient neighbors, and that, if violence occurred, it was directed toward family and friends rather than strangers. A longstanding debate concerns the interpretation of the finding of a higher prevalence of mental disorders in the lower social classes and in deprived city areas, where the ‘social causation’ and the ‘social selection drift’ hypotheses rival for explanation (Fox 1990). Recently Loffler and Hafner’s (1999) study in Germany supported the social drift theory, while Fox (1990) had concluded earlier that there was very little, if any, empirical support for social selection drift processes in serious mental illness. The epidemiological approach to suicide using published statistics has been a topic of much controversy since Durkheim’s (1897) seminal study. Douglas (1967) has denied the usefulness of this approach, and suggested that the only scientific topic worthwhile studying is the social meaning of suicide, i.e., the motives of those who kill themselves. A recent review on the sociological literature on suicide is provided by Stack (2000).

Typical problems on the microsocial level which have been studied by sociologists (partly in conjunction with psychiatrists) are: Stigma, quality of life and satisfaction, illness behavior, life events, the emotional climate within the family (‘expressed emotion’) and its relation to relapse in schizophrenia, social support, coping, compliance and the process of caregiving for the chronic mentally ill, homelessness, and the work environment. Phelan et al. (2000) found that people with psychosis are more feared today than they were in the 1950s. Markowitz (1998) studied the effects of stigma on the psychological well-being and life satisfaction of persons with mental illness, and Link et al. (1987) looked into the effects of stigma on recovery. Rosenfield (1992) found that the single most powerful influence on the improvement of subjective quality of life of the chronic mentally ill was the improvement of the individual’s actual power in terms of economic status. Katschnig et al. (1997) have reviewed the concept of quality of life in relation to mental disorders, and Jackson et al. (2001) have summarized research on predictors of patient satisfaction. Mechanic (1995) relates these issues to the concept of illness behavior, arguing that the disability process is specifically relevant to promoting function and maintaining patients’ quality of life, especially in primary care settings, where patient motivation should be increased, helpful attitudes encouraged, coping strategies taught, family members and employers educated, and support provided.

Finally, services research as well as studies which evaluate the functioning of psychiatric services in terms of quality control (Scheid and Greenley 1997) and mental health policy papers (Mechanic 1994) are further examples of sociological involvement in psychiatric issues.

4. Conclusion

As this review has shown, there are numerous points of contact between sociology and psychiatry, and each can learn much from the other. This is especially true at a time when the focus of psychiatry is moving further back into the community, and consumer participation and a ‘civil dialogue’ are becoming more important. Qualitative research methods, which seek to explain quantitative findings, generate hypotheses and ensure that questionnaires are relevant, are an appropriate tool for accompanying this process (Chard et al. 1997). Also, it might be useful to develop a sociology of the relationship between sociology and psychiatry. This review could serve as modest point of departure for such an undertaking.

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