Howard B Kaplan. Handbook of Social Problems: A Comparative International Perspective. Sage Publications, 2004.
No human condition is intrinsically problematic in any group. It becomes socially problematic when it is defined as such, whether by the population at large or by some segment of the population that is particularly influential in developing and implementing social policy directed toward forestalling or alleviating the conditions evaluated as undesirable. The condition may be labeled as socially undesirable either because it is intrinsically noxious or has intrinsically distressful consequences.
Mental illness has been defined as such a problematic condition because it is intrinsically distressing, it impedes the proper performance of social roles, whether by the afflicted individual or those with whom the individual interacts, or otherwise has consequences that are deemed dysfunctional for the social system. Not the least of these consequences are the social costs of providing responses (preventative or therapeutic programs) aimed at forestalling or assuaging the symptoms of mental illness.
Thus, major depression is now said to be the primary cause of disability, and mental disorders account for 4 of the top 10 causes of disability internationally (World Health Organization [WHO] 2001).
Mental illness is socially problematic not only because of its consequences but also in the sense that among the causes are a wide range of social conditions and circumstances. The resolution of the social problem requires that these factors be recognized and taken into account in the formulation of policies aimed at forestalling or assuaging the magnitude of the problem.
Finally, mental illness is socially problematic because of the absence of a broad consensus on the nature of mental illness. Without consensus, it is not possible to gauge the extent of mental illness in the population and therefore to plan for the number and kind of preventative or remedial services that would be required to obviate or relieve the symptoms. Nor would it be possible, in the absence of consensus, to address the causes that form the basis for social planning to prevent or eradicate the conditions that might consensually be defined as mental illness.
Author’s Note: This work was supported by research grants (R01 DA 02497 and R01 DA 10016) and by a Career Scientist Award (K05 DA 00136) to the author from the National Institute on Drug Abuse.
In the following pages, we consider in turn these three socially problematic aspects of mental illness: the processes by which states that are designated as mental illness come to be socially defined as problematic; the social causation of the conditions that are socially designated as mental illness; and the social consequences of mental illness.
Defining Mental Illness as Socially Problematic
From the social problem perspective, the definition of mental illness is central to two issues. The first issue concerns the socially constructed nature of mental illness and the reality of the referents of the construct. The second issue relates to the prevalence and distribution of cases according to whatever concepts and measures of mental illness have gained favor in the society.
Mental Illness as a Social Construct
At the outset, the distinction must be drawn between the social attribution of mental illness and the phenomena that evoke the attribution. Behaviors, including the communications of thoughts, feelings, and perceptions, may appear universally but be attributed to mental illness only in certain societies. In other societies, the behaviors in question may be attributed to simple malevolence or physical illness. The responses that are signs of mental illness may be incorporated into social roles as appropriate to those roles. The social roles themselves may be defined as deviant, but in those deviant roles, the behaviors may be appropriate to the role. Even in societies in which the concept of mental illness exists, the groups of which the individual is a part may find the attribution of mental illness to be too threatening to the continuity of the group and so may be normalized or otherwise defined in more acceptable terms, such as “eccentric” rather than “mad.” Whether or not certain behaviors or the psychological structures that are inferred from such behaviors will be interpreted as indications of mental illness depends upon the cultural context, including the social identities of the individuals displaying the behaviors.
When and where the concept of mental illness or some functionally equivalent term exists, behavioral manifestations or putative underlying psychological structures that are said to be indicative of mental illness fall within one or more of the following categories:
- Severe and Prolonged Subjective Distress. Whether or not the occurrence of severe and prolonged and subjective distress is understandable in light of an individual’s unfortunate life circumstances, the presence of distressful states such as chronic depression or anxiety are often taken to be indicative of mental illness. The affective states are intrinsically undesirable and, furthermore, may have consequences that are socially undesirable, as when chronic depression results in social withdrawal and the concomitant failure to perform normal social roles, and so prevents performance of complementary social roles.
- Affective or Cognitive Aberrations. A wide variety of situationally inappropriate affective and cognitive responses are taken to be indicative of mental illness regardless of the cause of the aberrations. Included under this rubric would be impaired memory functions, sensory distortions, contrary-to-fact beliefs that resist change when confronted with reality, and euphoric responses in situations that are conventionally expected to produce dysphoric or affectively neutral responses. Loss of memory, cognitive confusion, or hallucinations due to a blow to the head or substance abuse would be included, as would delusions or hallucinations that are traceable to severe and prolonged distress and that function more or less effectively to assuage the distress (delusions of persecution may serve the function of justifying one’s failure and at the same time signify that the subject is sufficiently important so as to elicit persecutory responses). Euphoric emotional responses that are inappropriate or disproportionate to the situation, whether due to delusions, hallucinations, or substance abuse, would also be included under this rubric.
- Psychogenic Biological States. Frequently, undesirable physical states are classified under the rubric of mental illness, particularly when they are regarded both as intrinsically undesirable and as traceable to psychogenic antecedents such as severe and prolonged subjective distress. Cases in point are unfortunate outcomes such as hysterical blindness, catatonic states, and psychophysiological disorders.
- Psychogenic Behaviors. Many overt behaviors are said to be indicative of mental illness when they are both intrinsically undesirable and are directly or indirectly caused by prior impairments of cognitive or affective functions, that is, are outcomes of the first two categories of indicators of mental illness. Cases in point include violent behaviors that result from delusional beliefs (“the devil made me do it”), buying sprees that stem from manic disorders, and deviant behaviors that reflect attempts to forestall or assuage distressful feelings of self-derogation, as when substance abuse reflects the attempt to avoid circumstances that give rise to distressful self-feelings and when violence represents the need to attack the validity of conventional standards according to which the person must regard himself or herself as unworthy (Kaplan 1986,1996).
The conception of mental illness, particularly in contemporary Western cultures, has overwhelmingly been influenced by the dicta of the psychiatric profession. The pronouncements of this group serve as the gold standard for describing what is and what is not mental illness. For the psychiatrist, “mental illness” refers to “a spectrum of syndromes that are classified by clusters of symptoms and behaviors considered clinically meaningful in terms of course, outcome, and response to treatment” (Bruce 1999:37). Arguably, the categorization of forms of mental illness most widely used in the world today takes the form of the American Psychiatric Association’s Diagnostic and Statistic Manual of Mental Disorders (DSM-W-tr).
Particular behaviors or cognitive and affective processes are labeled as mental illness by professionals with greater or lesser success depending upon a number of features of the social interaction among the professionals and their acquiescence or resistance to political influence. As Switzer, Dew, and Bromet (1999) observe:
Numerous examples of the influence of social and political context on the definition and assessment of mental disorders can be found simply by charting the flow of diagnostic categories into and out of the DSM. The recent creation and addition of posttraumatic stress disorder (PTSD) to the DSM was a direct result of concerted post-Vietnam War lobbying efforts by American military veterans. The elimination of homosexuality as a diagnostic category was a result of lobbying by gay and lesbian organizations, changes in prevailing societal attitudes, and the greater willingness on the part of the medical community to acknowledge the lack of empirical evidence that homosexuality reflects psychopathology. (P. 97)
The definition of mental illness as the public and psychiatric profession conceive of it has important implications for setting public policy. The most significant issue stemming from the conceptualization of mental illness is the j udgment of the magnitude of the social problem.
Estimating Prevalence of Mental Illness
Surveys in a range of developed countries suggest that more than 25 percent of persons manifest one or more mental (including behavioral) disorders) during their lifetimes (Almeida-Filho et al. 1997; Wells et al. 1989; WHO 2001). However, the rates vary from country to country, and so do the estimates of services that will be required to deal with the social problem that is mental illness. We will focus on the United States as a case in point, recognizing the uncertainties in estimating the prevalence of mental disorder(s) there and in other countries (WHO 2001).
Satisfaction of the need for general population data on the prevalence and distribution of various forms of mental illness was facilitated by the development of the Diagnostic Interview Schedule (DIS) (Robins et al. 1981), a research diagnostic interview that could be administered by trained lay interviewers. This instrument was initially used in the Epidemio-logic Catchment Area (ECA) study of over 20,000 respondents interviewed in five separate community epidemiological surveys (Robins and Regier 1991).
Since the ECA study was carried out in metropolitan areas, the results do not generalize to the portion of the population living in rural areas. In part, this limitation was addressed by the National Comorbidity Survey (NCS), funded by the National Institute of Mental Health (NIMH), using a sample said to be representative of the entire United States (Kessler et al. 1994). The NCS interview used the Composite International Diagnostic Interview (CIDI), a modified version of the DIS (Robins et al. 1988). Many of the accepted generalizations regarding the distribution of psychiatric disorders in the community are based upon the results of the ECA and NCS studies (Kessler and Zhao 1999). After adjustments were made for methodological differences, the two studies were observed to be similar in disorder-specific or overall prevalence rates.
According to the NCS (Kessler et al. 1994), approximately 50 percent of the sample reported a lifetime history of at least one of the psychiatric disorders surveyed. Approximately 31 percent of the sample reported at least one disorder during the preceding year. The most common single disorder was major depression. When considering broad classes of disorders, addictive disorders and anxiety disorders were more prevalent than mood disorders or other disorders. When considering the year prior to the interview, anxiety disorders were the most prevalent (Kessler and Zhao 1999).
When considering only severe and persistent mental illness (including nonaffective psychosis, bipolar disorder, severe forms of major depression, autism, panic disorder, and obsessive-compulsive disorder) or serious mental illness (including those disorders that markedly interfere with major life activities), excluding addictive disorders from either definition, the 12-month prevalence rates for these two categories were estimated to be 2.6 percent and 5.4 percent, respectively. The least-inclusive category of serious and persistent mental illness encompassed an estimated 4.8 million afflicted individuals. The more inclusive category of serious mental illness encompassed 10 million individuals. If institutionalized residents are included, an additional 2.2 million people are estimated to have serious and persistent mental illness, numbering 12.2 million in the total population (Kessler and Zhao 1999).
The mental illnesses that are counted in the general population tend to be concentrated in a relatively small proportion of the population. As Kessler and Zhao (1999) observe,
Only 21% of all the lifetime disorders occurred to respondents with a lifetime history of just one disorder, which means that the vast majority of lifetime disorders (79%) are comorbid disorders…. Close to six out of every ten (58.9%) disorders in the past year, and nearly nine out of ten (89.5%) severe disorders during this time, occurred to the 14% of the sample having a lifetime history of three or more disorders. These results show that… the major burden of psychiatric disorder is concentrated in a group of highly comorbid people who constitute about one-sixth of the population. (Pp. 136-37)
Such descriptive epidemiology of the mentally ill is a necessary tool for public advocacy. Arguments could be made regarding the need for mental health services and their location on the basis of the number and kinds of cases that were counted in the population, their distribution according to social characteristics, and their presence in various geographic areas. However, in evaluating the utility, reliability, and validity of concepts and methods employed in the study of mental illness, we must never lose sight of the fact that evaluations in this regard are the outcome of social influence processes and have no worth except insofar as they reflect what is problematic from the perspective of particular socionormative frameworks.
Social Causation of Mental Illness
From a global perspective, it is apparent that the correlates of mental illness are highly variable. Rates of suicide are relatively high in rural areas of China. At the same time, it has been observed that in low- and middle-income countries, poverty in urban areas summarizes a range of stressors that foreshadow or are otherwise associated with psychiatric disorders (Desjarlais et al. 1995; WHO 2001). Common psychiatric disorders have been observed to be about twice as prevalent among the poor as among the rich in surveys of Brazil, Chile, India, and Zimbabwe (Patel et al. 1999).
Unique concatenations of causes have been postulated for patterns of mental health and illness in different countries, including, for example, the breakdown of traditional forms of social structures in African societies during colonial rule and dislocations stemming from armed conflicts and other disasters in African and Asian societies (Desjarlais et al. 1995).
Variability is observed as well in the forms of psychiatric disorder that are observed transnationally. Thus, the ratio of brief reactive psychoses to schizophrenia may be lower in Europe and North America than in certain underdeveloped societies (Desjarlais et al. 1995). The range of psychosocial factors affecting the onset and stability of various forms of mental illness is perhaps most apparent in the studies conducted in the United States.
The design and implementation of effective public responses to mental illness depends upon an understanding of the causes of the genesis and continuity of mental disorders. While not ignoring the impact of biogenetic, environmental, and other factors, it is widely recognized that social structures and processes exert important influences on the genesis, continuity, and mode of expression of mental disorders. The literature addressing the social causation of mental illness primarily addresses four issues: the effects of social identities on the genesis of mental illness; intervening social stress-related processes; social factors that influence the form or expression of mental illness; and factors that influence the (dis)continuity of mental illness.
Social Identities and Mental Illness
Every person has numerous social identities that specify the rights and obligations incumbent upon that person within a network of social relationships. These identities are frequently considered to be among the more powerful explanatory constructs employed in the study of the social causation of mental illness (Kaplan 1972). The significance of social identities for the genesis of mental illness may be illustrated with reference to the literature relating to social identities differentiated according to socioeconomic status, race/ethnicity, marital and parental status, and employment/occupational statuses.
Socioeconomic Status (SES). One of the more robust findings in the literature on mental illness is the inverse relationship between SES and mental health status. For example, in a follow-up of a community sample 16 years later, lower-SES subjects were observed to have a greater probability of developing first episodes of depression and anxiety during the intervening years (Murphy et al. 1991). The inverse relationship between SES and prevalence of mental illness observed in the United States has also been observed in countries throughout the world (Desjarlais et al. 1995).
SES influences mental illness through a number of intervening processes. Lower SES increases the number of stressors one experiences and also is associated with paucity of resources that might have mitigated stress (McLeod and Kessler 1990). SES is positively related to occupations characterized by direction, control, and planning; and such occupations are less likely to be associated with depression (Link, Lennon, and Dohrenwend 1993). Poverty, or its correlates, such as being on welfare rolls, is intrinsically stigmatizing and often leads to feelings of self-inefficacy and related dysphoric moods (Goodban 1985; Popkin 1990).
Living in impoverished neighborhoods, in addition to being intrinsically distressing, may exhaust ability to cope with stress, cause the adoption of (mal)adaptive defense mechanisms such as chronic mistrust or suspicion, and erode feelings of having control over one’s own destiny, with the result that the residents despair of ever improving their lot, a loss of hope that is reflected in severe depression (Halpern 1993; Massey and Denton 1993; McLeod and Nonnemaker 1999; Wilson 1991).
Race/Ethnicity. Numerous studies report associations between race or ethnicity and mental illness. For example, Hispanics manifest higher prevalence of both mood disorders and active comorbidity compared with non-Hispanic whites (Kessler and Zhao 1999).
Different ethnic and racial groups evoke differential degrees of esteem or derogation in the general population. This translates into internalization of self-concepts that are self-accepting or self-derogating. Intrinsically distressing self-attitudes, in turn, evoke stress-inducing coping patterns (e.g., hypervigilance) and in the extreme, psychopathological responses. Particular racial and ethnicity-based social identities also lead to adverse outcomes in the form of barriers to approximation of consensually valued goals. Failure to achieve such goals, in turn, increases the probability of pathological outcomes (Akbar 1991; Carter 1993; Essed 1991; Kaplan and Marks 1990).
The probability of perceiving personal traits as stigmatizing depends in part upon whether or not the traits in question are normative in the person’s immediate social context. Thus, McLeod and Edwards (1995) reported that impoverished Hispanic and American Indian children living in areas where others were of like race and ethnicity had fewer internalizing and externalizing problems than children who lived in areas where other races and ethnicities were prevalent (Tweed et al. 1990).
The influence of race on psychiatric disorder is moderated by gender and SES. Thus, Williams and associates (1992) observed that low-SES African American women have higher rates of substance abuse disorders than low-SES whites. Unexpectedly, however, low-SES white males have higher rates of psychiatric illness than low-SES African Americans. Perhaps “low social status for a white male in a white-dominated culture may be so dissonant from societal expectations that it can produce serious psychological consequences” (Yu and Williams 1999:157). Alternatively, African Americans may have greater access to coping resources that mitigate the adverse effects of stress on mental health (Williams et al. 1997).
Marital and Parental Status. Separated, divorced, or widowed adults have higher rates of psychiatric disorders than married people. The relationship is stronger for certain disorders such as depression. In contrast, never-married people do not differ markedly from married people in lifetime prevalence rates, although they did have higher rates of disorders during the preceding 12 months (Kessler and Zhao 1999; Umberson and Williams 1999).
The relationship frequently observed between being married and the absence of depressive symptomatology may be accounted for in part by the influence of being married on greater perceptions of social support and mastery that, in turn, are inversely related to depressive symptomatology (Marks 1996; Mirowsky and Ross 1989; Ross and Mirowsky 1989; Turner and Marino 1994; Turner and Turner 1999). Mediating the relationship between divorce and adverse mental health status may well be the economic hardship and social isolation that is attendant upon single parenting, consequences that, in turn, increase the likelihood of poor mental health status (Kitson and Morgan 1990). The relationship between marital status and mental illness is a conditional one:
So important is marital quality for women, in fact, that the current mental health of married women in bad marriages is worse than that of divorced women. The opposite is true of men, though, in whom mental health is better among those in bad marriages than among the divorced. (Kessler and Zhao 1999:143)
Divorce may be more threatening to white women than to African American women because divorce is more likely to carry a stigma among the former group (Gove and Shin 1989). For men, widowhood is more threatening because it requires adaptations that sorely test their sense of self-sufficiency (Umberson, Wortman, and Kessler 1992). Furthermore, perhaps because widowhood is less expected among the young, it has a more adverse effect on mental health status for the young (Gove and Shin 1989).
The relationship between entering into parenthood and adverse consequences for mental health status may be mediated by the negative impact of parenthood on marital quality and (especially for women) the greater responsibilities incumbent upon the new parents, responsibilities that they may not be prepared for (Cowan et al. 1985; Hackel and Ruble 1992; Nock and Kingston 1988). When certain moderating conditions are present (natural resources, child care, and social support), parenthood may be associated with greater mental health (Gove and Geerken 1977; Ross and Huber 1985; Ross, Mirowsky, and Huber 1983). In the absence of such supports, however, for women, demands of family and work place them in a conflict situation that leads to higher levels of depressive symptoms.
Employment and Occupational Status. Homemak-ers, the disabled, the unemployed, and the retired have higher lifetime prevalence rates of psychiatric disorder than workers and students. For 12-month prevalence rates, workers have better mental health than adults in all other categories (students, homemakers, the unemployed, disabled, and retired) combined (Kessler and Zhao 1999). Indirectly, macrosocial conditions such as the general state of the economy influence individual mental health both by increasing the probability of unemployment and (even for the employed) the perception of poor economic conditions and consequent stressful feelings of job insecurity (Brenner 1987; Catalano, Rook, and Dooley 1986).
Features of the job situation influence mental health. Thus, the experience of close supervision and the presence of job insecurity, as well as low income, affect mental health status for men but not for women (Adelmann 1987; Lennon 1987; Lowe and Northcott 1988; Miller 1980). In contrast, lower substantive complexity of work and the absence of helpful coworkers adversely affected the mental health status of women but not of men (Lowe and Northcott 1988; Miller 1980).
Social identities have consequences that under specified conditions influence mental health status for better or worse. These intervening and moderating factors in large measure reflect social stress-related processes.
Social Stress and Mental Health
The social stress process as it is related to mental illness implicates constructs related to stressful life events and role strain; intrapersonal and interpersonal mechanisms (coping and social support); negative self-feelings (self-derogation); and patterns of mental illness that either express negative self-feelings or serve as more or less effective modes of forestalling, assuaging, or otherwise coping with negative self-feelings and their causes.
Role Strain and Stressful Life Events. In the course of the socialization process, individuals learn to accept, and in varying degrees to value, their social identities and the obligations incumbent upon them when they occupy those identities. At different times in life, different identities and associated role obligations become more or less important. If the person fails to meet the standards that apply to these identities in a particular situation, then he or she will experience distressful self-rejecting feelings. The intensity of the distress experience will depend upon the value placed on the social identities and the associated obligations that the person fails to meet. For example, for highly valued social identities such as parent, how well one nurtures one’s children is a salient standard for self-evaluation. The ongoing inability to fulfill role expectations associated with valued social identities is experienced as role strain.
Discrete experiences that have implications for fulfillment of role expectations and the occupancy of (dis)valued social identities represent stressful life events. Directly, events may induce stress by virtue of being intrinsically disvalued. The event reflects the anticipation or current experience of inability to fulfill felt obligations. Less directly, life events may be stress inducing through either of two pathways. First, life events may result in the disruption of the person’s normal and characteristic ways of forestalling experiences of adverse life events, or mitigating the intensity and duration of concomitant subjective distress. Second, life events may impose new requirements on individuals, the fulfillment of which is problematic. To the extent that these new expectations are unfulfilled because they require resources that were heretofore adequate but are now inadequate, the person will experience a self-devaluating/stress-inducing sense of failure (Kaplan, Robbins, and Martin 1983).
Illustrations of the stressful effects of chronic role strain and life events associated with particular social identities abound in the literature. Chronic role strains may result, for example, from serving as a caregiver to a mentally ill family member or from conflicts in societal and occupational roles. The strains that an individual experiences as a member of a group containing a mentally ill person (Avison 1999) may be the result of having inadequate resources to fulfill a socially obligatory role or the recognition that in fulfilling the role of caregiver, the person is unable to fulfill the legitimate expectations that are associated with other social positions that the individual occupies simultaneously. For example, the person may be unable to continue being a good mother while expending her energy as a caregiver to a mentally ill husband.
Regarding stressful life events, loss of a job or interruptions in marital status may instigate or exacerbate levels of anxiety and depression (Kessler, House, and Turner 1987). The child who experiences divorce may suffer both poorer parenting and economic adversity following the divorce that contributes to later mental illness (George 1999; Harris, Brown, and Bifulco 1990; Landerman, George, and Blazer 1991).
Men and women respond differentially to life events that have differential evaluative significance. Thus, wives tend to experience psychological distress in response to undesirable/uncontrollable events, while husbands tend to experience psychological distress in association with undesirable/controllable experiences (Thoits 1987). The inability to accomplish roles within their control may be especially threatening to the masculine self-image. Women who experience interpersonal problems are prone to depression, while men appear to be more vulnerable to depression when encountering job stress and income loss, that is, problems relating to the breadwinner role (Kaplan 1970; Kessler and McLeod 1984; Radloff and Rae 1981).
Often, early childhood adversity may have a moderating effect on the experience of later adversity such that individuals who experienced early negative life events may suffer a greater experience of distress when later life events occur (Landerman et al. 1991). Thus, for adults below the age of 30, but not for other adults, current self-rejecting feelings were associated with reports that during childhood, subjects were very much afraid of being punished by their parents and that they received poorer grades than most of the children they knew (Kaplan and Pokorny 1970).
Coping and Social Support. Among individuals who experience equivalent levels of disvalued life circumstances, individuals characterized by certain social identities may possess more or less efficient personal and interpersonal resources to mitigate the experience of the psychological distress that would ordinarily accompany such circumstances. These resources might include defensive patterns that permit the denial or redefinition of the self-devaluing significance of the circumstances after the fact, or that provide interpersonal resources that counterbalance the distressful self-feelings. For example, women are not only less likely to use effective mechanisms but are also frequently more likely to use dysfunctional mechanisms, such as selective ignoring responses, which in marriage and parenting actually exacerbate stress rather than assuage it (Pearlin and Schooler 1978).
It has been argued that the increase in depressive symptoms observed for subjects in their 60s could be accounted for by increased cognitive disability and consequent decreased ability to cope with stressors (Krause 1999). The inability to cope successfully influences perceived loss of personal control and so increases depression during the sixth decade of life. This process might be mitigated by the presence of strong social support networks.
Social support refers “to the clarity or certainty with which the individual experiences being loved, valued, and able to count on others should the need arise” (Turner and Turner 1999:302). Empirical studies have widely reported a buffering effect of social support. For example, depression is more likely to develop following the experience of stressors among those individuals who lack social support compared with those who possess social support (Henderson 1992).
Negative Self-Feelings. The inability to forestall or assuage the impact of identity-related role strain and adverse life events through the effective use of coping mechanisms and interpersonal resources results in negative self-evaluation and consequent negative self-feelings. Indeed, the stressful nature of particular life circumstances lies in their threats to the self-esteem motive. For example, the inability to exercise discretion on the job, partly reflected in the close supervision the individual is subject to, influences low self-esteem and high levels of anxiety and depression (Kohn and Schooler 1983; Link et al. 1993). Among the antecedents of high self-esteem are beliefs that one has control over one’s own life (Mirowsky, Ross, and Van Willigen 1996).
Numerous theories posit the existence of a self-esteem motive that becomes activated in the face of threats to one’s positive self-attitudes. Among these theoretical orientations are self-derogation (Kaplan 1972, 1980, 1986) and self-affirmation theory (Steele 1988). Increasingly, from such perspectives, stressors have in large measure been interpreted in terms of their implications as threats to self-evaluation (Thoits 1999). Kaplan and his associates have perhaps been most consistent in viewing the stress process in terms of the self-threatening nature of life circumstances and mental illness as a reflection of more or less functional adaptations to such threats (Kaplan 1972, 1986, 1996; Kaplan, Boyd, and Bloom 1964; Kaplan and Meyerowitz 1970; Kaplan et al. 1983; Lorimor, Kaplan, and Pokorny 1985). Intrinsically disvalued social positions or identities evoke attitudes of social rejection and, consequently, distressful feelings of self-rejection (Williams et al. 1997). If people are emotionally invested in performing the social roles associated with their identities in the social system, the failure to perform these roles appropriately will evoke self-disapproving attitudes and concomitant self-derogation. Such self-contemptuous attitudes frequently are indicative of mental illness or stimulate pathological responses that represent maladaptive attempts to reduce self-contempt and restore self-accepting attitudes (Kaplan 1986; Thoits 1999).
Mental Illness and Self-Derogation. The failure to obviate assaults upon salient self-evaluative standards by social stressors frequently results in severe and prolonged negative self-feelings (low self-esteem). Low self-esteem, in turn, is implicated in the genesis and stability of mental illness. As Thoits (1999) observes,
It is virtually impossible to develop a theory of the etiology of mental illness without thinking about self and identity issues. Almost all approaches in psychiatry and clinical psychology (with the exception of behaviorism) view individual’s mental health as at least partly influenced by positive self-conceptions, high self-esteem, and/or the possession of valued social identities. (P. 345)
From the perspective of self theory (Kaplan 1996), mental illness frequently is the expression of negative self-feelings or consciously or unconsciously motivated responses that are intended to serve self-protective or self-enhancing ends. As a reflection of intrinsically distressful self-feelings, the perception of life circumstances as threatening to salient self-evaluative standards often manifests itself in anxiety, depression, posttraumatic stress disorders (PTSD), and generally, in dysphoric states. A number of psychodynamic models of anxiety states focus on threats to the individual’s self-acceptance (Eells et al. 1993):
In Sullivan’s theory, an interpersonal context—specifically, the anticipated unfavorable appraisal by significant other—produces anxiety. For Horney, anxiety is triggered in the context of an individual’s attempts to actualize an idealized self. … In Kohut’s model, disintegration anxiety occurs when an individual’s selfobjects fail to supply self-esteem needs adequately. (P. 118)
While anxious patients are characterized by feelings of vulnerability, depressed patients are characterized by feelings of worthlessness (Beck 1976). It is the end result of being unable to think well of one’s self in the face of wanting to think well of one’s self (Tesser 1986).
Threats to self-evaluation characterize dysphoria in general and PTSD in particular. McNally (1993) states:
In addition to anxiety and depression, PTSD patients experience other emotional disturbances that suggest alterations in self-representation (Horowitz, 1986). Soldiers who kill noncombatants or participate in atrocities often experience intense guilt about performing acts profoundly inconsistent with their self-concept as a moral being (March, 1990). (P. 73)
From the perspective of many self theories (Kaplan 1996), a number of psychiatric disorders are consciously or unconsciously motivated by the need to forestall self-threatening experiences or to assuage the accompanying distressful self-feelings; and, under specified conditions, they actually decrease negative and increase positive self-feelings. Substance (ab)users may experience an increased sense of self-efficacy, increased feelings of power, suppression of self-awareness of unfavorable self-images, and a sense of belonging in groups where substance (ab)use is countenanced (Kaplan 1986). Violence has also been interpreted as a defense against negative self-feelings. Scheff, Retzinger, and Ryan (1989) assert: “Anger can be a protective measure to guard against shame, which is experienced as an attack on self (p. 188). Psychopaths maintain a sense of superiority and deal with anxiety by focusing upon emotionally neutral, externalized aspects of behavior and by admitting to and describing their socially undesirable traits during the clinical interview (LaBarba 1965).
So pervasive is the view of many psychiatric disorders as functioning to assuage negative self-feelings that much of contemporary psychoanalysis has been characterized “as a mode of investigation for understanding the vicissitudes of self-development and defensive processes that are invoked to protect the self (Cooper 1993:46). For Epstein (1993), individuals characterized by delusional systems have sacrificed a need to assimilate the data of reality for a need to enhance self-esteem. Similarly, for Laing (1969), schizophrenia is a workable adaptation to an incoherent world, a way of dissociating from unbearable social circumstances.
For Adler (Ansbacher and Ansbacher 1956), the inferiority complex is at the core of neurosis. To conceal their perceived inferiority from others and themselves, neurotics engage in a variety of safeguarding strategies, including the enhancement of their own self-esteem and sense of superiority by deprecating others. At the same time, the failure of such persons is accounted for by those people and circumstances who are the objects of their aggression. Obsessions and phobias, specifically, may serve avoidance functions and so defend against threats to self-esteem (Salzman 1965).
The specific mechanisms underlying the attempts to satisfy the need for self-acceptance via psychiatric disorders may be illustrated with anorexia ner-vosa, depression, and narcissism. From numerous perspectives (Vitousek and Ewald 1993), anorexia nervosa is frequently perceived as a way of dealing with the distress associated with confirmation of being unworthy through experiences of failure. The preanorexic adolescent comes to believe that losing weight will alleviate distress. The anorexia provides feelings of success, pride, and superiority, as well as increased sense of self-control, and evokes attention and concern from others.
While depression may be an expression of negative self-feelings, at the same time, it may be considered a defense against such feelings (Epstein 1993; Norem and Cantor 1986; Pyszczynski and Greenberg 1987). Adopting a negative self-image provides relief from the person’s futile attempts to maintain a positive self-image. The person attempts to control the emotional reaction to self-threatening circumstances rather than to control the occurrence of such circumstances. By keeping expectancies for positive outcomes low, the person minimizes disappointment.
The narcissist “depends on continual infusion of admiration and approval to bolster an uncertain sense of self-worth” (Giddens 1991:172). For Kohut (1971), the grandiose self is interpreted as a defensive structure that helps the child to deal with (whether through minimization or denial) parental disappointments.
Clinical and theoretical formulations of the relationship between negative self-feelings and psychopathology are compatible with the results of longitudinal studies on large in-community populations (Kaplan 1989; Kaplan et al. 1983). For example, analyses of the first three waves of data of a longitudinal study of adolescents suggest that over one or two years, self-derogation anticipates subjective distress and other behavioral responses interpretable as antecedents or reflections of psychopathology. Subjects who were more self-rejecting were significantly more likely to be referred for psychiatric treatment. The same population in young adulthood revealed an association between self-derogation scores in the 7th grade and self-reports 10 years later of several psychopathological patterns during the intervening time. Numerous other studies indicate, as well, that low self-esteem is associated with subsequent reports of psychological distress, other modes of psychopathology, and antisocial behavior (DuBois et al. 1994; Rosenberg, Schooler, and Schoenbach 1989).
These findings have implications for the prevention and treatment of psychiatric disorders. They sensitize policymakers and therapists to the self-devaluing implications of interpersonal arrangements and to the self-enhancing or self-protective functions of pathological patterns, and therefore to the need to forestall self-devaluing circumstances and/or to facilitate more acceptable and effective response patterns than the pathological patterns that for the mentally ill represent the best adaptations available to them. In short, above all, it must be recognized that mental illness frequently serves important functions for the individual and that until alternatives to resolving the individual’s needs are provided, mental illness must suffice as an adaptive mechanism of choice.
Form or Expression of Mental Illness
Social factors influence not only the probability of individuals developing some form of mental illness but also the likelihood of developing particular forms of mental illness.
Cultural and Identity-Specific Variability. Cultural variability in the prevalence of mental illness in general or in particular forms of mental illness is apparent in a number of studies (Agbayani-Siewert, Takeuchi, and Pangan 1999). Leighton and Hughes (1961) cite a number of specific constellations of symptoms that are observed in given areas of culture and that appear to reflect culturally patterned beliefs and practices. For example, “Witiko,” observed among the Ojibwa Indians, is frequently characterized by the subject’s killing and eating members of his own family. He is said to believe himself possessed by a cannibalistic monster (the Witiko), a being that appears in the traditional mythology of the culture.
Wittkower and Dubreuil (1968) also note cultural variations in the patterns of symptoms associated with traditional diagnostic categories. Thus, with regard to schizophrenia, catatonic body rigidity and negativism are said to be relatively common among the Indian population. Relative to the classical picture of schizophrenia observed among Europeans in general, Asiatic schizophrenics are noted as displaying less aggression and more withdrawal, while southern-Italian patients are said to display more aggression and less withdrawal.
Form of mental illness has been observed to vary within the same society according to social identity as well. One of the more robust findings in psychiatric epidemiology relates to gender-based differences in the forms that psychiatric disorder takes (Rosenfield 1999):
Females suffer more than males from internalizing disorders, including depression and anxiety, which turn problematic feelings inward against themselves…. More often than men, women live with fears in the forms of phobias, panic attacks, and free-floating anxiety states. In contrast, males predominate in externalizing disorders, expressing problematic feelings in outward behavior. They more often have enduring personality traits that are aggressive and antisocial in character, with related problems in forming close, enduring relationships. (P. 210)
Normal Coping and Form of Mental Illness. A number of observations in the literature are congruent with the thesis that forms of mental illness are extrapolations from normal coping mechanisms observed in cultures, subcultures, or in association with particular social identities (Kaplan 1972). As a basis for one investigation, Figelman (1968) postulated that cultural differences exist between Jews and African Americans (“Negroes” was the term used in the original research) with regard to patterns of coping with aggression and that these cultural differences are reflected in variability in patterns of psychopathology. It was expected that Jewish subjects would be more likely than African Americans to manifest affective disorders (involving either depression or hypomanic defenses against depression) since the Jewish subjects would tend to internalize anger, a pattern that is congruent with the Jewish prohibition against the open expression of anger. African Americans would be more likely to manifest paranoid disorders “because the outward expression of aggression permissible in Negro culture allows for the frequent use of projection as a defense” (Figelman 1968:278). As expected, comparisons of Jewish and African American patients indicated that the former were significantly less likely to display paranoid disorders and were significantly more likely to manifest affective disorders than were the African American subjects.
Breen (1968) also contrasts the cultural styles of American Jewish and African American subjects and relates these styles to modes of psychopathology. The American Jewish culture embodies the cohesive, aggression-controlling style, while the African American culture is characterized in terms of the dispersive, aggression-expressing style. In the event there is a schizophrenic break for whatever reason, it is to be expected that the symptomatic expression of the disorder would reflect, in the extreme, certain aspects of the culture in which the schizophrenia was observed. Thus, the Jewish schizophrenic is likely to be diagnosed in terms of varieties of dependency schizophrenia, including simple, hebephrenic, and catatonic schizophrenia. In contrast, the African American in the event of a schizophrenic break would be expected to receive a diagnosis of paranoid “because, in his deterioration, the fear of assault that he has always lived with will be exaggerated” (Breen 1968:284). Observations of male schizophrenic patients supported the hypothesis that the Jewish patients would be more likely to receive diagnoses of schizophrenia and that the African American patients would be more likely to receive diagnoses of paranoid. Thus, the findings are in accord with the viewpoint that schizophrenic sympomatology reflects exaggerations of culturally patterned lifestyles for coping with extreme stress (Kaplan 1972). The pattern of differences in expressions of mental illness for males and females noted above are also interpretable as extensions of differential socially sanctioned coping patterns for males and females.
Social policy dedicated to the reduction of mental illness requires consensus on the nature of mental illness. Policymakers must recognize that mental illness is expressed differently in different groups. By focusing on only one kind of expression, much mental illness (by other standards) might go unrecognized and untreated.
Course of Mental Illness
Social factors influence the course of mental illness as well as the onset and form of psychological disorder. The course of the disorder is influenced by whether or not the person comes into treatment, what happens to the person in treatment and following treatment, and other consequences of being diagnosed as mentally ill.
Entry Into Treatment. One estimate suggests that approximately 70 percent of individuals with needs for mental health services (that is, with mental health disorders) do not receive needed services. Furthermore, only 12 to 13 percent of those with mental health disorders receive services from mental health specialists (Howard et al. 1996; Polgar and Morrissey 1999; Regier et al. 1993). While it might be argued that in certain circumstances, the failure to receive mental health care might be salutary, in general it may be presumed that the failure to receive care, whether due to absence of facilities or barriers to the utilization of such care (and other factors that affect motivation to use available systems of care), would have adverse consequences on the course of the illness (Polgar and Morrissey 1999).
Therapeutic Experiences. For those who enter into treatment relationships, the course of treatment will depend upon a number of factors that enter into the treatment experience. For example, race and ethnicity influence the responses of psychiatrically ill individuals to particular therapeutic modalities. Lawson (1986) indicates that Asians and African Americans respond to psychotropic drugs more quickly and with lower doses than whites. Self-derogation is implicated in the degree of posthospitalization adjustment in the community (Harder et al. 1984; Lorimor et al. 1985). Change in self-derogation level and its ability to predict community adjustment was interpreted in terms of reestablishing the patient’s belief in his or her own worth during the course of hospitalization (Lorimor et al. 1985).
The level of posthospitalization expectations also influences the course of illness. Thus, outcomes of schizophrenia appear to be more favorable in less developed countries than in more developed countries, where schizophrenia takes more chronic forms (Sartorius et al. 1976), outcomes that may be attributable to the observation that less developed societies tend to have lower expectations for performance by the mentally disordered and place less stigma on them (Hopper 1992; Horwitz 1999; Waxier 1974).
Former mental patients in the community face a number of problems that increase the likelihood of their being returned to mental hospitals. They are discharged into the community, often prematurely, and are faced with hostility, limited opportunities, and inadequate aftercare programs. They assume the social roles of the unemployed and often go onto welfare rolls. The situation is exacerbated with the passage of legislation that results in the mass release of patients without providing for individualized aftercare programs (Gallagher 2002).
Consequences of Labeling. The very fact of labeling particular behaviors or affective and cognitive processes as indicative of mental illness has consequences for the course of the “mental illness” (Link et al. 1987; Link et al. 1989). While being labeled as mentally ill may not in itself cause mental illness, it is reasonable to believe that it contributes to the continuity of mental illness by evoking attitudes of social rejection, foreclosure of social opportunities, and self-derogatory attitudes (Markowitz 1998; Phelan and Link 1999; Rosenfield 1997; Wright, Gronfein, and Owens 2000). Fearfulness and increased social distance are among the consequences of perceiving previously hospitalized mental patients to be dangerous (Link et al. 1987; Martin, Pescosolido, and Tuch 2000). The label of mental illness exacerbates the patient’s self-rejecting attitudes since he or she recognizes the stigmatizing implications of the label. The further erosion of self-respect and a sense of mastery exacerbates preexisting symptoms of depression or other disorders and so may be expected to contribute to a relapse in the posttreatment experience of the former patient (Link et al. 1989; Markowitz 2001; Wright et al. 2000). Indeed, stigmatizing aspects of the therapeutic process lead mental patients to resist committing to the patient role and allow themselves to do so only by compartmentalizing their lives on the psychiatric ward into mutually exclusive “therapeutic” and “nontherapeutic” spheres (Kaplan et al. 1964). Furthermore, the patient may adjust to the stigmatized patient role by focusing on the positive aspects of the status, thus stabilizing a career as mentally ill (Kaplan 2000).
This brief review of the social factors implicated in the genesis, form, and continuity of mental illness suggests that mental disorder is in part a socially caused problem and that the recognition of the social causes has the potential to be part of the solution to the problem. In the last analysis, the effectiveness of attempts to reduce the scope of the problem of mental illness must rest upon a sound knowledge of the etiology of mental disorders. Successful public health measures cannot be formulated unless it is understood that the environmental conditions with which these programs are concerned are influential in the genesis of psychopathological states.
In evaluating the total current body of knowledge regarding the causes of mental illness, one may take the pessimistic view that this body consists of a mass of largely unrelated and often inconsistent findings derived by dubious methodology, lacking both a unifying conceptual framework and systematic theory; or one may take the more optimistic point of view that great strides have been made in the employment of rigorous methodology, increasing consensus regarding relevant theoretical orientations and a body of observations that await systematic interpretation in the context of systematic theories. For the sake of motivating research efforts toward the goal of understanding the causes of the phenomena grouped under the label of mental illness, it behooves us to accept the more hopeful view and to put forward theoretical frameworks and research agendas that would serve to systematize our understanding.
Social Consequences of Mental Illness
The consequences of mental illness may be thought of as falling into two categories: (1) responses by social groups in which the illness is observed and (2) the functioning of the social systems in which the mentally ill hold membership.
Responses to and consequences of mental illness vary from country to country. Thus, in several developing nations, psychiatric care is not available; and where such care is available, it takes the form of custodially rather than therapeutically oriented mental hospitals. Indeed, it might be said that in several countries, the modal response is not response since they have no mental health policies or programs (Desjarlais et al. 1995; WHO 2001). In Western Europe, in contrast, a deemphasis on mental hospitalization is apparent. In the eastern Mediterranean region, an integration of mental health services with general health care patterns may be observed. In more developed countries, mental health care systems have moved from a centralized system to one in which policy determination and implementation responsibilities have been transferred to local administration (WHO 2001).
In terms of dysfunctional consequences of mental illness, studies in Europe have indicated that expenditures on mental illness represent an appreciable portion of all health service costs (Meerding et al. 1998; Patel and Knapp 1998). In countries where direct costs are low, indirect costs in terms of loss of productivity nevertheless are estimated to be quite high (Chisholm et al. 2000).
In some reports, the responses to and consequences of patterns of mental disorder throughout the world are paralleled by those in the United States, while in other respects, they diverge markedly.
Responses to Mental Illness
We consider, in turn, the responses of the mentally ill themselves; the primary membership groups of the mentally ill; the general public; professional groups; and groups responsible for the setting and implementation of policies relating to the mentally ill.
The Mentally Ill. How psychiatric disorder is responded to by the individual and by the groups in which the person holds membership is influenced by a number of factors other than the disorder itself. By one estimate, in a national sample, a mere 40 percent of the persons who met the criteria for psychiatric illness received treatment. Help-seeking by the person is preceded and/or precipitated by a number of factors, including the disruptive effects the patient’s symptoms have on the functioning of the groups in which the person holds membership; the perception by the person that his or her symptoms are serious; the insistence by others in the social network that the person seek help; the extent to which the symptoms are judged to be bizarre independently of their disruptive nature; the recognition by the individual that these symptoms reflect mental illness; and the actual and perceived availability of therapeutic resources, including the perception of barriers (cost, distance, and stigma) to utilization of the resources (Mechanic 1968; Zola 1964). The perceived availability of resources (including affordability and accessibility), in turn, is influenced by structural and organizational factors, including the actual existence of caregiving resources, transportation to and from the resources, health education programs that permit the potential user to know of the existence of these programs, health insurance systems that influence affordability, referral patterns among the professional community, and related factors (Polgar and Morrissey 1999; Stein and Test 1980).
Having decided that the seeking of help for emotional problems is warranted as a response to self-acknowledgment of signs or symptoms of mental illness, individuals will adopt any of a wide variety of responses, including speaking with relatives; seeking advice from friends; use of nonmedical professionals, including clergy or supervisors; using traditional healers; and, of course, self-referral to psychiatrists or other physicians (Pescosolido, Boyer, and Lubell 1999). Initially, subjective distress instigates help-seeking from family and friends. When seeking professional help, individuals are more likely to turn to physicians than to mental health specialists, although the tendency to seek help from mental health specialists appears to be increasing over the years (Veroff, Kulka, and Douvan 1981).
The precise nature of the source from whom help is sought is influenced by culture, group membership, and social identities. Thus, cultures characterized by collective versus individual orientations may be inhibited from using mental health services rather than membership groups to assuage symptoms of mental illness (Kashima and Triandas 1986); and loss of face to the individual’s membership groups may pose an impediment for Asian Americans in making a decision to seek help from mental health professionals for symptoms of mental illness (Ja and Aoki 1993). More religious people will seek help from religious functionaries, and if one’s friends are prone to use psychotherapists, the afflicted individual will be more likely to seek help from such a source (Kadushin 1969). Self-identification as mentally ill and use of mental health professionals is more likely to occur among the more educated, women, and younger people (Horwitz 1982).
Membership Group Responses. The tendency of the public to define mental illness in terms of the more psychotic disorders is paralleled by the disposition of family members to deny, rationalize, and otherwise minimize the significance of emotional and cognitive disorientation of another family member. Often, the disorder reaches the attention of the practitioner only after the occurrence of extremely disruptive behavior with which the family cannot cope. The end result is a long delay between onset of symptoms and family influences on seeking help (Clausen and Radke-Yarrow 1955). Having a close family member who is mentally ill is more likely to evoke responses of denial, normalization, and concealment than is having a more distant relative who is afflicted with signs of mental illness (Horwitz 1982).
Responses by primary group members are influenced by their social identities within and outside the family. Thus, care of the mentally ill generally falls to female relatives (Cook 1988; Gamache, Tessler, and Nicholson 1995); and ethnic minorities engage in more informal care, find provision of care less burdensome, and are less likely to rely on professionals than are white families (Horwitz and Reinhard 1995; Jenkins 1988; Lefley 1987).
Public Responses. The disposition of the problem of mental illness depends in large measure on the responses of the general public with regard to the definition of mental illness, attitudes toward the mentally ill, beliefs about the causes and functions of mental illness, attitudes toward modes of treatment, and predispositions to seek help for symptoms. Regarding definition, over the years, there has been an increasing tendency for the general population to adopt the perspective of psychiatrists regarding the kinds of behaviors that could appropriately be labeled mental illness. However, the population is still loathe to (by any great majority) identify a wide range of behaviors as indicative of mental illness. In the cases of the most severe psychiatrically judged disorders (paranoid and simple schizophrenia), the general population comes closer to adopting psychiatric standards (Kaplan 1972).
Regarding attitudes, in the mass media and in public conceptions, mentally ill individuals connote the morally unsavory, dangerous, and unsuccessful (Phelan et al. 1996; Shain and Phillips 1991; Signorelli 1989). The very fact of entering into a helping relationship with a mental health professional or in an institution functioning to provide care increases the stigma attached to the mentally ill person (Phillips 1963). In part, this may be accounted for by the fact that observers may frequently have difficulty in evaluating behavior as symptomatic of serious mental disturbance. However, knowledge that an individual has sought help from a psychiatrist or has become hospitalized serves to reduce any ambiguity and to identify the individual’s behavior to the observer as a relatively serious mental disturbance (Kaplan 1972).
Beliefs about the causes and functions of mental illness held by the general public are not unsophisticated. As recently as 35 years ago, the general public appeared to view mental illness as a way of dealing with or as result of difficult current life situations (Elinson, Padilla, and Perkins 1967). Close to 77 percent of the respondents in one study agreed that “although they usually aren’t aware of it, many people become mentally ill to avoid the difficult problems of everyday life”; and a like percentage agreed that “mental illness often grows out of a tough situation that a person gets into and cannot handle.”
Attitudes toward mode of treatment reflect beliefs in support of the efficacy of psychiatric care and the belief that such care involves diagnosis and treatment primarily by psychotherapeutic methods (Kaplan 1972). Public attitudes toward mental hospitalization appear to reflect ambivalence in the simultaneous expression of at least three motives: to be protected and/or relieved of the annoyance of mentally ill people, to provide proper care for the mentally ill, and to assuage any guilt that results from the recognition that mental hospitalization might be of limited benefit to the patient (Elinson et al. 1967; Kaplan 1972). In response to florid psychiatric symptoms that severely disrupt ongoing group functioning, substantial portions of the population are willing to employ legal coercion to channel individuals with drug abuse problems or those who are symptomatic for schizophrenia into mental health treatment (Pescosolido et al. 1999).
The various responses that the social order makes to mental illness are mutually influential. For example, because mental illness is defined as illness rather than morally reprehensible behavior means that social control mechanisms that are put in place will take the form of the delivery of medical care rather than more overtly punitive responses, such as nontherapeutic incarceration. When people believe that mental illness is caused by stress, the response will be to provide services that forestall or assuage the experience of distress, but when mental illness is thought to be physiologically based, the disorder will be treated by drugs.
Professional Responses. Arguably the most influential framework for conceptualizing and otherwise responding to the phenomenon of mental illness is the medical model (Cockerham 2003). Increasingly, conditions that were once not thought of as medical problems have come to be viewed in this way; that is, deviant behaviors have been medicalized (Conrad and Scheider 1992). Medicalization involves making claims to the general public and legislative authorities by formal medical organizations that the “deviant” behavior is essentially a medical problem, gaining legitimization of the medical interpretation of the behavior from legislative bodies, and institutionalizing the behavior as a medical problem by formal professional recognition of it as such (Conrad and Schneider 1992).
The public has increasingly come to accept the medical specialty of psychiatry as the legitimate arbiter of the nature and proper treatment of the mentally ill. Frequently, psychiatric nosology is interpreted in terms of labeling of deviance, and psychiatric treatment is recognized as serving a social control function (Tausig, Michello, and Subedi 1999).
In support of this interpretation, studies may be cited (Loring and Powell 1988) that indicate a tendency by white male psychiatrists to diagnose African Americans and women differently than white males, controlling on presenting symptoms. “Existing evidence suggests that persons with social characteristics that differ from those of labelers (psychiatrists) are more apt to have deviant behavior labeled as psychiatric disorder” (Tausig et al. 1999:118). That is, individuals who are deviant in some respects are more likely to be labeled as deviant in other respects (Kaplan 2000; Stiles and Kaplan 1996).
Public Policy. Ultimately, the resolution of the social problem of mental illness will depend upon the formulation and implementation of public policies directed toward ameliorating either the putative causes or the adverse consequences for the individual and society. Some suggestions have been made to effect public policy changes at the macrosocial level. For example, Yu and Williams (1999:163) observe, “There is a need for a renewed commitment to reduce the inequalities in societal institutions that appear to be the basic causes of social inequalities in health” (citing Williams and Collins 1995). Since hospitalized patients upon their return to the community frequently become symptomatic again (Mechanic 1999), it would seem that social policy should direct attention to remediation of the environmental circumstances that give rise to or exacerbate the person’s disposition to become mentally ill.
Most policies related to mental illness, however, have been directed toward treatment of the mentally disordered. Over time, the form that these services and systems take changes markedly (Polgar and Morrissey 1999):
In the United States, four cycles of reform have developed and shifted responsibilities for administration of mental health services among governmental and private interests over the past 200 years (Morrissey, Goldman, & Klareman, 1985). These reforms focused on asylums in the early nineteenth century, mental hospitals in the early twentieth century, community mental health centers in the 1960s, and community support systems in the 1980s. A fifth cycle of reform, involving the growth and evolution of managed care, is currently generating important new questions about the organization and utilization of mental health service delivery (Mechanic, Schlesinger, & McAlpine, 1995; Morrissey, Johnsen, Starrett, Calloway, & Polgar, 1996). (P. 463)
Each of these cycles has their own causes and consequences. For example, the noteworthy shift in care of the mentally disordered from the mental hospital to the community was brought about by the confluence of a number of factors, including the deplorable state of the public mental hospital, the availability of psychotropic drugs, the enormous expenses associated with adequate custodial care, the increasing awareness of the number of mentally ill in the community who remained untreated, legal decisions requiring treatment of the mentally ill in the least-restrictive settings, and newly emerging philosophies of treatment promulgating the maintenance of the patient in the community (Tausig et al. 1999).
The influence of the federal government in combating mental illness is apparent in three earlier pieces of legislation. The National Mental Health Act of 1946 led to the establishment of NIMH a few years later. NIMH engaged in intramural research programs on the causes and treatment of mental illness; they promoted research, professional training, and the development of intense treatment programs through grants to education, research, and treatment institutions as well as to state governments in the form of matching grants. The Mental Health Study Act of 1955 permitted the authorization of a nongovernmental study group, the Joint Commission on Mental Health and Illness, to carry out an intensive nationwide analysis of the mental health problem and to formulate recommendations for a national mental health program. The final report of the Joint Commission on Mental Illness and Health (1961) led to the third major legislative act, the Hill-Harris bill of 1963. Of particular interest is Title II of Public Law 88-164, which authorized the granting of $150 million in federal matching grants to states for the construction and establishment of comprehensive community mental health centers. At the very minimum, the centers were to provide inpatient, out-patient, partial hospitalization, emergency, and consultation and educational services. However, the failure of these programs to provide adequate aftercare for patients released into the community ultimately resulted in large numbers of individuals going untreated for their mental illness (Torrey 1997). Many of the untreated population were homeless, and somewhat more than that number were imprisoned or jailed frequently for crimes associated with their mental illness.
These outcomes, along with changes in administrations, led to new policies at the national level (Kirk 1999):
The Reagan revolution effectively ended NIMH’s power to direct and shape mental health services by consolidating 10 federally funded alcohol, drug abuse, and mental health initiatives into a single block grant to each state….
By 1980, the bad press brought about by deinstitutionalization, in tandem with the public preferences for a non-activist federal government, put NIMH into retreat from any bold new services agenda. From the progressive and activist stance of the early reformers, the Institute, along with much of American psychiatry, turned full steam to the safer harbor of biomedicine…. The Institute turned increasingly from the community to the laboratory, from social reform to biological science, from concern with social structures to brain chemistry. (Pp. 550-51)
Each of these policy changes has important implications for better or worse care of the mentally ill. Some of the consequences of recent policy trends cannot be anticipated with any certainty. A recent trend in the delivery of mental health services implicates the evolution of managed care systems, a development that many think will have adverse consequences for the care of the mentally ill (Gallagher 2002).
Some policies address specific aspects rather than the total problem. A case in point is the question of civil commitment. The concepts of dangerousness and unpredictability are inextricably linked in the public mind with the concept of mental patients (Hiday 1995; Rosenfield 1997), a stereotype that is reflected in legal procedures for civil commitment that permit enforced treatment of individuals who are determined to pose a danger to themselves, others, or their property. Such procedures exist even in the face of serious questions regarding the possible violation of constitutional rights that is implicit in the civil commitment process (Hiday 1988).
It has been argued that if the goal of policymakers in the United States is to provide an effective health care delivery system for those afflicted with mental disorders, then these policymakers have failed miserably. The system for health care delivery, indeed, has been defined as a “nonsystem” (Cockerham 2003):
The existing health care delivery system is a conglomerate of health practitioners, agencies, and institutions, all of which operate more or less independently. There often is little or no effective planning or coordination, with the result that has been (1) a duplication of services, which increases the cost of care; (2) a maldistribution of services, which translates into a relative abundance of resources in affluent urban areas in contrast to limited resources in urban poverty and rural areas; and (3) a lack of comprehensiveness and continuity of care. Moreover, there is no national system of health insurance, and many people cannot afford by themselves to pay for quality medical care. (P. 302)
This assessment, by implication, dictates the major policy issues that require attention in the contemporary United States. However, these issues will be addressed only when political pressure is exerted upon these policymakers to define mental illness as a critical and unresolved social problem. How they are addressed will be determined by balancing diverse and frequently conflicting values, including those related to economic and political self-interest, public safety, civil liberties, and humanitarian concerns.
Individual and Group Functioning
Mental illness has consequences for the functioning of the individual in various social contexts and for the groups in which the individual participates.
Individual Functioning. Independent of the costs in distress suffered by the mentally ill, mental illness has consequences as well for adoption of social roles and for functioning in the social roles that are adopted or assigned. Mental illness also has implications for family formation and dissolution in that individuals with histories of mental illness are more likely to get divorced and less likely to marry, and when marrying, are more likely to do so at an earlier age (Forthofer et al. 1996; Gotlib and McCabe 1990; Mastekaasa 1992). A history of mental illness is associated with a number of adverse consequences for the mentally ill individual. In particular, the history of mental illness is associated with lower levels of occupational, income, and educational attainment (Clark 1994; George 1999; Kessler et al. 1995). Such individuals are also more likely to have unstable work histories (Clark 1994) and to develop work-related disabilities (Broadhead et al. 1990).
Some of the consequences of mental illness may be secondary effects of being labeled mentally ill rather than of the illness itself. The experience of rejection in response to being labeled as mentally ill anticipates aspects of mental illness, such as depressive affect, even after controlling for earlier depressive symptoms and expectations of rejections (Link et al. 1997).
Group Functioning. Patterns of mental illness have a variety of direct or indirect consequences that have an impact on the functioning of more or less inclusive social groups in which the mentally ill person holds membership. These include the family, the industrial sector, and the more inclusive society. Caring for a mentally ill person places a great strain upon other family members. Family members find themselves bereft of resources to fulfill their roles, and time demands placed upon them put them in conflict situations such that they cannot fill one role except by ignoring another. Insofar as one individual is unable to fulfill his or her appropriate role because of conflicts in time demands, the ability of individuals to fulfill their complementary roles is affected as well. Furthermore, roles that were formerly played by the mentally ill person now must be performed by others in the family, thus placing further burdens on an already overburdened system. Finally, relationships with systems outside the family are adversely affected insofar as the person must necessarily reduce interaction with friendship and neighborhood groups, as well as make adjustments in work performance schedules (Tausig et al. 1999). Furthermore, readjustments are necessary when hospitalized mental patients return to the family (Cook and Pickett 1987; Fisher, Benson, and Tessler 1990; Noh and Avison 1988).
Patterns of mental illness have adverse effects on the workplace as well (Kessler and Zhao 1999):
There is increasing awareness that people with psychiatric disorders have considerably more work loss days than others (Broadhead, Blazer, George, & Kit, 1990; Johnson, Weissman, & Klerman, 1992). Concerns have been raised that psychiatric disorders might also be related to workplace accidents and voluntary job leaving, both of which are very costly for employers. These considerations have led some commentators to argue that employer-sponsored health insurance that offers generous provisions for mental health coverage should be seen as an investment opportunity rather than a cost of doing business (Kessler & Frank, 1997). (P. 145)
Finally, the costs of providing a health care delivery system are provided at the expense of other social needs. In American society, as it may be presumed in other societies, mental illness has been estimated to have enormous direct and indirect costs. Direct costs, counting the treatment of substance abuse, have been estimated to be more than 297 billion in tax payer dollars and private costs .Added to this are in direct costs in loss of workforce productivity (79.3 billion per year), exclusive of loss of income from substance abuse and related psychoses, and loss of productivity associated with the homeless mentally ill (Gallagher 2002).
We have said that the social costs of mental illness are great, whether considering the costs of the programs put in place to treat the mentally ill or in terms of the loss of human capital in the workplace and family. If mental illness is regarded as socially problematic, then society should be motivated to formulate and implement effective policies toward forestalling or assuaging the adverse effects of mental disorders. Whenever causes of mental disorder are recognized, these policies should be formulated in ways that take those causes into account. The eradication of the social problem, then, requires an understanding of its causes, the design of appropriate interventions based on such understanding that might forestall mental illness or ameliorate its adverse individual and social consequences, and the collective will to implement social policies that define mental illness as a critically important social problem. Lacking scientific understanding, enlightened public policies based on such understanding, or a leadership that defines mental illness as a social problem deserving precedence, mental illness will continue to be a de facto social problem.