BritishJournalof Psychiatry(1992),161, 594—598

Annotation

Sociology in the Context

of Social Psychiatry

BRIAN COOPER As part of its concern with the environmental causes of disease, medical research tries to comprehend the nature of social processes and their implications for

human health: an endeavour calling for sociological concepts and methods (Susser eta!, 1985). Medical needs are mirrored within sociology, which has never been confmed to study of the workings of society, but has always concerned itself also with their impact on individuals and on public health. The importance of cooperation between the two disciplines is thus indisputable. Nevertheless, interprofessional relationships

have never been easy, and Pflanz's

dictum, that “¿the history of the relationship between sociology and medicine is. . . mainly a history of unsuccessful encounters― (Pflanz, 1976), remains substantially true today. The difficulties have been ascribed to interdisciplinary tensions of the kind that arise when a relatively young academic profession seeks to assert its autonomy in a relationship with an older-established and more powerful one. Martin (1976),

stressing

the dangers

that

can result

from

more specifically, for the development of a scienti fically based social psychiatry. If the latter discipline can be fairly characterised as a three-legged creature, with one foot in psychiatry, one in epidemiology, and one in the social sciences (Schwab & Schwab, 1978, p. 3), its stability is rendered all the more precarious by poor coordination between its limbs. The links between psychiatry and general epidemi ology remain weak because, as Sartorius (1989) has emphasised, many epidemiologists refuse to take mental disorder seriously as a subject for research. This situation, however, can be expected to resolve itself as public-health priorities change, and at least there is little disagreement about the research strategies and methods that will have to be applied. Cooperation between psychiatry and sociology, on the other hand, faces more fundamental obstacles: in the field of empirical research their relationship has become increasingly problematic over the past three decades, as a result of diverging questions, aims, and methods (Lawson, 1989).

mutually false expectations, invoked the analogy of a marriage in which: Differences of aim and method ki field research “¿.. . no

one

questioned

that

medicine

was

the

male

partner,

kindly, benevolent, but a bit of a chauvinist. However, it turned out that the bride was a dedicated member of the

women's liberation movement,and intended to spend her time in marriage, not performingher duties alongthe lines laid down by her partner, but in proclaiming

the autonomy

of sociologyand denouncing medical domination.― Martin's conclusion that the case for a closer integration in teaching and research should not be pressed too hard, and that sociologists can best contribute their special skills if they are encouraged to do so as equal partners, has been endorsed by a number of sympathetic observers on both sides. Underlying the interprofessional disputes and rivalries there are more fundamental differences: issues both of method and of substance continue to divide the thinking of medical and social scientists, not least in the mental health field. The purpose of this annotation is not to attempt a review of the extensive literature on mental health sociology, but to highlight some problems of communication which seem important for interdisciplinary research and,

Any comprehensive analysis of mental illness has to encompass a series of stages, ranging from the observation and monitoring of various types of abnormal behaviour, via their definition in terms of pathology or social deviancy, to the search for causal explanations. The later the point at which sociological theory is introduced into this process, the less controversial it will be, and the more readily cooperation can be established between psychiatrists and social scientists. The biggest difficulties in communication have arisen at the early stages of analysis, in which psychiatric disorder as a legitimate medical concern has to be distinguished from other causes of social deviance also involving distress and abnormal behaviour. Since the decision to attribute behavioural abnormality to mental illness, or to some other cause, cannot be explained in medicopsycho

logical terms alone, but is in part determined by the social system, questions need to be posed about the forces that impel each society to stigmatise a larger or smaller proportion of its members as mentally ill,

Discussion paper presented at the World Psychiatric Association's Section Symposium on “¿Psychiatric Epidemiology and the Social Sciences―,Oslo, 14—16June 1991.

594

SOCIOLOGYIN SOCIAL PSYCHIATRY

595

and to apply relatively harsh or mild sanctions to other categories of illness, but as a constant reminder them. that any case definition or diagnostic label is useful Labelling theory, as invoked in this context by only to the extent that it serves as a predictive tool Scheff (1963, 1966) and others, has never had much (though not as a self-fulfilling prophecy) and helps appeal to clinical psychiatrists, whose sphere of to promote improved standards of treatment and competence it challenges and who, after all, have to care. deal with some of the less pleasant consequences of If problems of labelling and case definition can what Scheff disarmingly refers to as “¿residual be resolved, so that the sociologist can accept deviance―. Many sociologists with practical and work comfortably with psychiatric diagnostic experience of mental illness have also concluded that rubrics, the way is then open to a fruitful col social-interaction theory has attached too much laboration in which the occurrence, course, and weight to the part that victimisation plays in outcome of mental disorder serve as the dependent psychiatric labelling, while failing to explain the variables of inquiry, while social characteristics are occurrence of ‘¿primary deviance' in the shape of new, numbered among the independent variables. Here acute mental disturbance (Gove, 1980). At the same there is much less cause for dissension, although time, the fall over recent decades in numbers of professional differences may still be apparent in the psychiatric long-stay patients has served to distract extent to which various associations at aggregate attention from the dangers that case ascertainment levels are attributed to ‘¿illness behaviour' as a may bring in terms of compulsory admission and sociocultural phenomenon, rather than to the chronic institutionalism. Labelling theory, in short, distribution of morbidity (Mechanic, 1978). has ceased to be fashionable. Differences in medical and sociological emphasis This diminution in academic interest does not, may also be apparent in the approaches to research however, seem entirely warranted. The pressure of strategy, design, and method, although admittedly social influences on case recognition and diagnosis the lines of tension are not always or only along cannot be dismissed as of marginal importance. professional boundaries. Fears of stigmatisation and rejection expressed by In earlier field surveys, psychiatrists examined discharged mental-hospital patients may be well variations in rates of mental illness, using ready-to founded (Link et al, 1987). Trends in psychiatric bed hand demographic indices derived from administrative numbers and mean duration of hospital stay could data. Many sociologists have expressed dissatisfaction be reversed in the years ahead, and in any case with this approach to any form of morbidity in analogous conditions are now to be found in the populations, finding it crude and unimaginative. In populations of prisons, after-care hostels, rooming the words of one of them: houses, and geriatric homes, as well as among the “¿Nothing is as sterile as demographic group comparisons. growing numbers of homeless persons. Moreover, Results analysed in relation to such categories as sex, age, the political abuse of psychiatry has given psychiatrists race, marital status, occupation and geographical region cause to beware of the professional risk of being arean essentialpart of the book-keepingof modernsociety. misused as agents of social control: a danger by In and of themselves, however, these rates offer little by no means restricted to the former Eastern Bloc way of explanation. .. . These may be convenient, easily countries. Western psychiatry, as ødegaard (1975) studied labels for subdividing populations, but they are not dynamicsocial ideas and cannot, exceptin a very limited acidly observed: way,representthe kind of socialphenomenathat maycause “¿. .

.

tends

towards

conservatism

in

its

attitude

towards

the social order. Our tranquillising therapy does somehow ‘¿help to maintain the capitalist system', while actually psychiatry should be a liberating force. The problem arises when one tries to decide what kind of liberation we as

psychiatrists can recommend as good for mental health.

Nevertheless,we should admit a responsibility, not only for social control, but also for social change.―

Clearly, therefore, the implications of social interaction theory for psychiatric diagnosis should continue to be taken seriously. Psychiatrists need always to keep in mind that ‘¿mental illness' is essentially a social construction (Eisenberg, 1989), not because this somehow distinguishes it from all

disease or anything

else.― (Suchman,

1967)

Suchman's point, while certainly valid, does not justify any neglect of the social macro-environment

in research. It is precisely because they are linked to psychosocial

stress in individuals

that the mass

aspects of education, housing, employment, social welfare, and migration remain central to social psychiatry. Provided it does not distract attention from these links, the current sociological trend towards more intensive investigation of the micro environment is wholly welcome. Its principal features are: the investigation of social phenomena whose measurement calls for special skills and must be undertaken at first hand (Brown, 1980); the

596

COOPER

replacement of descriptive cross-sectional surveys by analytical studies, in which the sequence of events is clearly defined and intervening variables are controlled for (Mechanic, 1989); and the scrutiny of risk and protective factors, whose effects are cognitively mediated and give rise in the individual to an awareness of some loss or threat in the one case, or of security and fulfilment in the other. In studies of this nature, the danger of contamination between psychiatric and social variables has to be guarded against, especially when both groups tend to converge towards the middle ground of personal interaction. These advances in research design and method have been reflected in the strategies of data analysis. In earlier studies, too much reliance was placed on cross-sectional data and correlational techniques it being argued, for example, that because less than 10% of the variance in rates for depression or schizophrenia can be accounted for by life events, the latter are unlikely to prove of clinical or preventive importance (Andrews & Tennant, 1978). Cooke (1987), in a useful paper, has pointed out the fallacy in this reasoning. Applying the same technique to the incidence of bronchial carcinoma revealed that cigarette smoking explained only 0.003% of the variance, simply because the great majority of smokers do not in fact develop lung cancer. Hence statistical methods must be applied which are more appropriate to the purposes of epidemiological research, such as estimation of relative risk and population attributable risk in controlled studies, and use of ‘¿proportional hazards' techniques in the analysis of longitudinal survey data (Allgulander & Fisher, 1986). Taken in conjunction, these advances in method have yielded an increase in the explanatory power of social variables, which leaves little room for doubt about their relevance in causal research. Nevertheless, biological and social lines of investigation remain largely separate, and a common foundation of scientific theoryis still lacking. The quest for a common theoretical basis Neither sociogenetic nor biological theories alone can provide a satisfactory explanation for the observed incidence and distribution of different mental disorders in populations, or for that matter for the forms of their clinical expression. To begin with, it is a truism that the disorders in question comprise a heterogeneous mix of organic, developmental, and psychoreactive conditions, whose causes are complex and interwoven. Thus, exposures to many risk factors of brain damage and maldevelopment, including paranatal insult, malnutrition, neurotoxic chemicals,

acquired immunodeficiency, accidental trauma, and chronic alcohol abuse, are deeply influenced by social policy and demand the attention of sociologists as well as of epidemiologists. The functional psychoses and neuroses raise more complex issues, both variation and constancy in the patterns of morbidity needing to be accounted for. While it is now axiomatic that the phenomena of psychiatric morbidity vary between societies (Littlewood, 1990; Leff, 1990), the consistency with which at least some psychiatric core symptoms are found across cultures, but also across phenotypes and gene pools, is not easy to explain in conventional terms either of sociocultural influence or of population genetics. Why, to cite Jablensky (1989), should patients as distant from each other in background and culture as a Yoruba farmer in Nigeria and a Danish fisherman share the same first rank symptoms of schizophrenia? Before trying to explain such apparently universal manifestations of psychopathology by means of a genetic reductionism, mediators should be sought, at the level first of psychosocial needs and ego defences, and then of underlying instinctual propensities. Awareness of the extent to which human social behaviour, whether normal or patho logical, is conditioned by such drives does not necessarily imply a recourse to structural genetic models (Gilbert, 1989). We may be more immediately concerned with a primary capacity for construing social interactions, analogous to those which have been postulated by universalist theories of language acquisition (Chomsky, 1972)and moral development (Snarey, 1985). If so, the means by which genetic and cultural inheritance contribute to this potential will provide a subject for interdisciplinary research for many years to come. But whichever direction such research may follow, one can safely predict that it will have to pay regard to man's evolutionary background. Over 25 years ago, Ruesch (1965) suggested that the fundamental aim of social psychiatry is to avoid or overcome the segregation of mentally sick persons from their reference group, by strengthening their coping abilities, improving their communication with the group, and offering them prospects of reintegration. The rationale of social treat ment, he affirmed, rests on three evolutionary principles: (a) that man is essentially a herd animal and separation from the herd painful to him (b) that each individual tries to avoid separation from the herd, while simultaneously main taining his own identity and status within it

SOCIOLOGYIN SOCIAL PSYCHIATRY (c) that the perception of marked differences between oneself and the rest of the herd gives

597

research, including a greatly increased in-put from sociology (Lyman & Scott, 1967).

rise to anxiety and tension, stemming from the

danger that one may be rejected and excluded from the herd: in evolutionary terms a fatal outcome.

The public-health imperative

Here the investigator is confronted by a central dilemma of social psychiatry, a discipline whose Is this anything more than an elaborate metaphor? search for causal factors of mental illness demands If so, what are the consequences for research in social an increased complexity in theory and methods that psychiatry? In view of the notorious difficulty of will take time to develop, yet which in its practical testing in human society hypotheses derived from the and service aspects must deal with public-health observation of other species, definitive answers to problems of great and growing urgency. This these questions cannot yet be anticipated. Indeed, dilemma may be partially resolved by adopting it seems questionable whether more recent attempts preventive goals (Cooper, 1990), since the history to establish an evolutionary paradigm for mental of public-health epidemiology, from cholera to illness, for all their greater sophistication, have bronchial carcinoma, has repeatedly demonstrated advanced far beyond Ruesch's broad concept. that effective preventive measures can precede the Wilsonian sociobiology has aroused great interest —¿ full causal elucidation of a disease. Aetiological largely because of the controversy about its supposedly inquiries in psychiatry, few of which offer prospects racist and sexist overtones (Hare, 1987) —¿ but so far of rapid success, are therefore best pursued in parallel has found little application to psychiatric theory or with preventively orientated epidemiological and research. The contemporary literature on so-called health-services research. ‘¿ethological psychiatry' (McGuire & Fairbanks, 1977) Sociologists can make invaluable contributions to and ‘¿palaeopsychology' (Bailey, 1987), while holding both these lines of investigation, but to do so they much of interest, gives at times the impression that will require a firm sense of direction and the ability its authors have taken from animal field studies to steer a steady course. They will have on one side only what seems to harmonise with their own the barren rock of abstracted empiricism —¿ a sterile psychodynamic or cognitive theories, and to lend information gathering at the behest of service them a patina of biological respectability. But a administrators and the whim of politicians - and on comparative ethology that served merely to reinforce the other the treacherous whirlpool of grand theory, existing notions about the mainsprings of human threatening to suck them down into a vortex of social behaviour could for practical purposes be academic obscurantism and triviality (Mills, 1959). dispensed with as superfluous, on the principle In this predicament it will be vital for them to of Occam's razor. If there were no more to it maintain communication both with psychiatrists and than that, sociological scepticism would be fully with other health-care professionals in or outside the justified. The crucial question is: do we find medical schools, whose work entails daily contact evidence

for

the

existence

of

phylogenetically

determined biosocial drives, whose expression in psychopathology is definable, and cannot be equally well explained in terms of individual development and

learning?

with the mentally ill, and to draw benefit from their practical experience.

References

Only if this is the case does it

seem realistic and useful to speak of an ethological psychiatry. For the present, however, this question must remain open. One line of inquiry which may prove of great importance for psychiatric epidemiology, because of its population-based frame of reference, is the investigation of human spatial needs (Esser &

Deutsch, 1977),their possible origin in an underlying, instinctual territorial drive (Edney, 1974), and their significance for the establishment of dominance hierarchies, for intraspecific aggression, and possibly also for the growth of personal identity. This is a field of study which, almost by definition, transcends professional boundaries and calls for interdisciplinary

ALLGULANDER, C. & FISHER,L. B. (1986) Survival analysis(or time

to an eventanalysis)and the Cox regressionmodel—¿ methods for longitudinal psychiatric research. Scandinavica,74, 529—535. ANDREWS, 0.

Acta

Psychiatrica

& TENNANT, C. (1978) Life event stress and

psychiatric illness. Psychological Medicine, 8, 545—549. BAILEY, K. 0. (1987) Human paleopsychology: Applications to

Aggressionand Pathological Processes.Hilisdale: Erlbaum. BROWN, 0.

W. (1980)

Sociology

and

psychiatry.

In Priorities

in

Psychiatric Research(ed. M. Lader), pp. 17—37. New York: Wiley. CHOMSKY,N. (1972) Language and Mind. New York: Harcourt, Brace, Jovanovich.

CookE,D. J.(1987) The significance oflife events asa causeof psychological and physical disorder. In Psychiatric Epidemiology: Progress and Prospects (ed. B. Cooper), pp. 67-80. London:

Croom Helm.

598

COOPER

COOPER,

B. (1990)

Epidemiology

and

prevention

in the

mental

MCGUIRE,

Human

territoriality.

Psychological

(ed.)

(1977)

Ethological

Free Press. The

social

construction

of mental

illness.

Psychological Medicine, 18, 1—19. ESSER, A. H. & DEUTSCH, R. D. (1977) Private

and interaction

territories on psychiatric wards: studies on non-verbal com munication of spatial needs. In Ethological Psychiatry (eds M. T. M. McGuire & L.A. Fairbanks), pp. 127-152. New York: Grune & Stratton. P.

(1989)

Human

Nature

and

Suffering.

Hillsdale:

Eribaum. Govs, W. R. (1980) Labelling and mental illness: a critique. In The Labelling of Deviance.Evaluating a Perspective(2nd edn) (ed W. R. Gove), pp. 53—109.Beverly Hills: Sage. Hi@aa,E. H. (1987) Sociobiology, the new synthesis: Edward 0. Wilson. British Journal of Psychiatry, 150, 709-711. JABLENSEY, A. (1989) An overview

of the World

Health

Rawnsley),

A.

pp.

(1989)

455—471.

A

London:

sociological

CULLEN,F. T., F@nc,

R. (1990)

From

categories

J., et a! (1987) The social

to contexts:

a decade

of

the ‘¿new cross-cultural psychiatry'. British Journal of Psychiatry, 156, 308—327. LYMAN, S. & ScoTT, M. B. (1967) Territoriality:

a neglected

sociological dimension. Social Problems, 15, 236—249. MARTIN, F. M. (1976) Sociology

in community

medicine:

sociology:

some

tensions

among

theory,

outcome, treatment and prevention of mental disorders. In Psychiatric der Gegenwart., Pd. 3: Soziale und angewandte Psychiatric. 2. Auflage (eds K. P. Kisker, J.-E. Meyer & H. MUller), pp. 151—198.Heidelberg: Springer. Pi@z, M. (1976) Sociology in community medicine. In Semmars in CommunityMedicine,Vol. 1: Sociology(edsR. M. Acheson & L. Aird), pp. 3—14.London: Oxford University Press. RUESCH, J. (1965) Social psychiatry:

an overview.

Archives

of

SARrORIUS,N. (1989) The World Health Organisation's views on the prevention of mental disorders in developed and developing

countries. In Epidemiology and the Prevention of Mental Dicon!ers(eds B. Cooper&T. Helgason), pp. 321-326. London: Routledge.

socio-anthropological

rejection of former mental patients: understanding why labels matter. American Journal of Sociology, 92, 1461-1500. LIrrLEWOOD,

Medical

ØDE0AAIW,0. (1975) Social and ecological factors in the etiology,

Routledge.

and

(1989)

method and substance. Journal of Health and Social Behaviour, 30, 147—160. Miu.s, C. W. (1959) The Sociological Imagination. New York: OxfordUniversity Press.

GeneralPsychiatry,12, 501-509.

perspective. In The Scope of Epidemiological Psychiatry (eds P. Williams, 0. Wilkinson & K. Rawnsley), pp. 35-52. London: Routledge. Larr, J. (1990) The new ‘¿cross-cultural' psychiatry. A case of the baby and the bathwater. British Journal of Psychiatry, 156, 305-307. LINK, B. 0.,

—¿

Organization

multi-centre studies of schizophrenia. In The Scope of EpidemiologicalPsychiatry(edsP. Williams, 0. Wilkinson& K.

& FAIRBANKS, L. A.

MECHANIc,D. (1978) Medical Sociology (2nd edn). New York:

Bulletin,

81, 959—975. EISENBERG, L. (1989)

LAWSON,

T.

Biology. New York: Grune& Stratton.

9—15. EDNEY, J. J. (1974)

GILBERT,

M.

Psychiatry: Psychopathology in the Context of Evolutionary

health field. Social Psychiatry and Psychiatric Epidemiology, 25,

comments.

In Seminars in Community Medicine, Vol. 1: Sociology (eds R. M. Acheson & L. Aird), pp. 16—19.London: Oxford University Press.

SCHEFF,T. J. (1963) The role of the mentally ill and the dynamics

of mental disorder: a research framework. Sociometry, 26, 436—453. —¿

(1966)

Being

Mentally

ill.

A

Sociological

Theory.

Chicago:

Aldine. SCHWAB,

J.

J.

& SCHWAB,

M.

E.

(1978)

Sociocultural

Roots

of Mental Illness: An EpidemiologicSurvey. New York: Plenum. SNAREY,J. R. (1985) Cross-cultural universality of social-moral development: a critical review of Kohibergian research.

PsychologicalBulletin,97, 202-232. SUCHMAN, E. A. (1967)

Social stress and cardiovascular

disease:

appraisal and implications for theoretical development. Milbank Memorial Fund Quarterly, 45, 109—113. SUSSER,

M.,

WATSON,

W.

in Medicine (3rd edn). Press.

&

HOPPER,

New York:

K.

(1985)

Oxford

Sociology

University

BrianCooper,MD, FRCPsych, DPM,Professor,Departmentof EpidemiologicalPsychiatry,CentralInstitute of Mental Health, Mannheim, Germany Correspondence: Zentralinstitut fürSeellscheGesundheit, D-6800Mannheim 1, 15 (Postfach 122 120), Germany